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Peña-López Y, Sabater-Riera J, Raj P. Severe respiratory syncytial virus disease. JOURNAL OF INTENSIVE MEDICINE 2024; 4:405-416. [PMID: 39310066 PMCID: PMC11411437 DOI: 10.1016/j.jointm.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 03/05/2024] [Accepted: 03/05/2024] [Indexed: 09/25/2024]
Abstract
The burden of respiratory syncytial virus (RSV) disease is widely recognized. Main risk factors for severe disease, such as extreme ages, chronic cardiopulmonary conditions, and immunosuppression, typically coincide with poorer outcomes. While the majority of RSV hospitalizations involve healthy children, a higher proportion of hospitalized adults with underlying conditions need intensive care. Presently, treatment primarily consists of supportive measures. RSV-induced wheezing should be distinguished from respiratory tract thickening, without response to bronchodilators. Obstructive RSV disease frequently overlaps with viral pneumonia. Non-invasive mechanical ventilation and high-flow oxygen therapy represented significant advancements in the management of severe RSV disease in children and may also hold considerable importance in specific phenotypes of RSV disease in adults. Most severe infections manifest with refractory hypoxemia necessitating more advanced ventilatory support and/or extracorporeal membrane oxygenation therapy. Although bacterial co-infection rates are low, they have been associated with worse outcomes. Antibiotic prescription rates are high. Accurately diagnosing bacterial co-infections remains a challenge. Current evidence and antibiotic stewardship policies advise against indiscriminate antibiotic usage, even in severe cases. The role of currently developing antiviral therapies in severe RSV disease will be elucidated in the coming years, contingent upon the success of new vaccines and immune passive strategies involving nirsevimab.
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Affiliation(s)
- Yolanda Peña-López
- Microbiome Research Laboratory (MRL), Department of Immunology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Pediatric Critical Care Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Global Health eCore, Vall d'Hebron Institute of Research, Barcelona, Spain
| | - Joan Sabater-Riera
- Intensive Care Department, Servei de Medicina Intensiva, IDIBELL-Hospital Universitari de Bellvitge, L´Hospitalet de Llobregat, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Prithvi Raj
- Microbiome Research Laboratory (MRL), Department of Immunology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Santos ACEZ, Caiado CM, Lopes AGD, de França GC, Eisen AKA, Oliveira DBL, de Araujo OR, de Carvalho WB. "Comparison between high-flow nasal cannula (HFNC) therapy and noninvasive ventilation (NIV) in children with acute respiratory failure by bronchiolitis: a randomized controlled trial". BMC Pediatr 2024; 24:595. [PMID: 39294604 PMCID: PMC11412039 DOI: 10.1186/s12887-024-05058-6] [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: 06/15/2024] [Accepted: 09/05/2024] [Indexed: 09/20/2024] Open
Abstract
BACKGROUND The objective of this study was to compare HFNC therapy to noninvasive ventilation (NIV/BiPAP) in children with bronchiolitis who developed respiratory failure. We hypothesized that HFNC therapy would not be inferior to NIV. METHODS This was a noninferiority open-label randomized single-center clinical trial conducted at a tertiary Brazilian hospital. Children under 2 years of age with no chronic conditions admitted for bronchiolitis that progressed to mild to moderate respiratory distress (Wood-Downes-Férres score < 8) were randomized to either the HFNC group or NIV (BiPAP) group through sealed envelopes. Vital signs, FiO2, Wood-Downes-Férres score and HFNC/NIV parameters were recorded up to 96 h after therapy initiation. Children who developed respiratory failure despite receiving initial therapy were intubated. Crossover was not allowed. The primary outcome analyzed was invasive mechanical ventilation requirement. The secondary outcomes were sedation usage, invasive mechanical ventilation duration, the PICU LOS, the hospital LOS, and mortality rate. RESULTS A total of 126 patients were allocated to the NIV group (132 randomized and 6 excluded), and 126 were allocated to the HFNC group (136 randomized and 10 excluded). The median age was 2.5 (1-6) months in the NIV group and 3 (2-7) months in the HFNC group (p = 0,07). RSV was the most common virus isolated in both groups (72% vs. 71.4%, NIV and HFNC, respectively). Thirty-seven patients were intubated in the NIV group and 29 were intubated in the HFNC group (29% vs. 23%, p = 0.25). According to the Farrington-Manning test, with a noninferiority margin of 15%, the difference was 6.3% in favor of HFNC therapy (95% confidence interval: -4.5 to 17.1%, p < 0.0001). There was no significant difference in the PICU LOS or sedation duration. Sedation requirement, hospital LOS and invasive mechanical ventilation duration were lower in the HFNC group. CONCLUSION HFNC therapy is noninferior to NIV in infants admitted with mild to moderate respiratory distress caused by bronchiolitis that progresses to respiratory failure. TRIAL REGISTRATION NUMBERS U1111-1262-1740; RBR-104z966s. Registered 03/01/2023 (retrospectively registered). ReBEC: https://ensaiosclinicos.gov.br/rg/RBR-104z966s .
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Affiliation(s)
| | - Carolina Marques Caiado
- Pediatric Intensive Care Unit, Hospital Municipal Infantil Menino Jesus, São Paulo, São Paulo, Brazil
| | | | - Gabriela Cunha de França
- Pediatric Intensive Care Unit, Hospital Municipal Infantil Menino Jesus, São Paulo, São Paulo, Brazil
| | | | - Danielle Bruna Leal Oliveira
- Microbiology Department, Universidade de São Paulo, São Paulo, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Orlei Ribeiro de Araujo
- Pediatric Intensive Care Unit, GRAAC, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | - Werther Brunow de Carvalho
- Pediatric Intensive Care Unit, Instituto da Criança, Universidade de São Paulo, São Paulo, São Paulo, Brazil
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Westhoff M, Neumann P, Geiseler J, Bickenbach J, Arzt M, Bachmann M, Braune S, Delis S, Dellweg D, Dreher M, Dubb R, Fuchs H, Hämäläinen N, Heppner H, Kluge S, Kochanek M, Lepper PM, Meyer FJ, Neumann B, Putensen C, Schimandl D, Schönhofer B, Schreiter D, Walterspacher S, Windisch W. [Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]. Pneumologie 2024; 78:453-514. [PMID: 37832578 DOI: 10.1055/a-2148-3323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
The guideline update outlines the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.Non-invasive ventilation (NIV) has a high value in therapy of hypercapnic acute respiratory failure, as it significantly reduces the length of ICU stay and hospitalization as well as mortality.Patients with cardiopulmonary edema and acute respiratory failure should be treated with continuous positive airway pressure (CPAP) and oxygen in addition to necessary cardiological interventions. This should be done already prehospital and in the emergency department.In case of other forms of acute hypoxaemic respiratory failure with only mild or moderately disturbed gas exchange (PaO2/FiO2 > 150 mmHg) there is no significant advantage or disadvantage compared to high flow nasal oxygen (HFNO). In severe forms of ARDS NIV is associated with high rates of treatment failure and mortality, especially in cases with NIV-failure and delayed intubation.NIV should be used for preoxygenation before intubation. In patients at risk, NIV is recommended to reduce extubation failure. In the weaning process from invasive ventilation NIV essentially reduces the risk of reintubation in hypercapnic patients. NIV is regarded useful within palliative care for reduction of dyspnea and improving quality of life, but here in concurrence to HFNO, which is regarded as more comfortable. Meanwhile NIV is also recommended in prehospital setting, especially in hypercapnic respiratory failure and pulmonary edema.With appropriate monitoring in an intensive care unit NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency.
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Affiliation(s)
- Michael Westhoff
- Klinik für Pneumologie, Lungenklinik Hemer - Zentrum für Pneumologie und Thoraxchirurgie, Hemer
| | - Peter Neumann
- Abteilung für Klinische Anästhesiologie und Operative Intensivmedizin, Evangelisches Krankenhaus Göttingen-Weende gGmbH
| | - Jens Geiseler
- Medizinische Klinik IV - Pneumologie, Beatmungs- und Schlafmedizin, Paracelsus-Klinik Marl, Marl
| | - Johannes Bickenbach
- Klinik für Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Aachen
| | - Michael Arzt
- Schlafmedizinisches Zentrum der Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg
| | - Martin Bachmann
- Klinik für Atemwegs-, Lungen- und Thoraxmedizin, Beatmungszentrum Hamburg-Harburg, Asklepios Klinikum Harburg, Hamburg
| | - Stephan Braune
- IV. Medizinische Klinik: Akut-, Notfall- und Intensivmedizin, St. Franziskus-Hospital, Münster
| | - Sandra Delis
- Klinik für Pneumologie, Palliativmedizin und Geriatrie, Helios Klinikum Emil von Behring GmbH, Berlin
| | - Dominic Dellweg
- Klinik für Innere Medizin, Pneumologie und Gastroenterologie, Pius-Hospital Oldenburg, Universitätsmedizin Oldenburg
| | - Michael Dreher
- Klinik für Pneumologie und Internistische Intensivmedizin, Uniklinik RWTH Aachen
| | - Rolf Dubb
- Akademie der Kreiskliniken Reutlingen GmbH, Reutlingen
| | - Hans Fuchs
- Zentrum für Kinder- und Jugendmedizin, Neonatologie und pädiatrische Intensivmedizin, Universitätsklinikum Freiburg
| | | | - Hans Heppner
- Klinik für Geriatrie und Geriatrische Tagesklinik Klinikum Bayreuth, Medizincampus Oberfranken Friedrich-Alexander-Universität Erlangen-Nürnberg, Bayreuth
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Matthias Kochanek
- Klinik I für Innere Medizin, Hämatologie und Onkologie, Universitätsklinikum Köln, Köln
| | - Philipp M Lepper
- Klinik für Innere Medizin V - Pneumologie, Allergologie und Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg
| | - F Joachim Meyer
- Lungenzentrum München - Bogenhausen-Harlaching) München Klinik gGmbH, München
| | - Bernhard Neumann
- Klinik für Neurologie, Donauisar Klinikum Deggendorf, und Klinik für Neurologie der Universitätsklinik Regensburg am BKH Regensburg, Regensburg
| | - Christian Putensen
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Bonn
| | - Dorit Schimandl
- Klinik für Pneumologie, Beatmungszentrum, Zentralklinik Bad Berka GmbH, Bad Berka
| | - Bernd Schönhofer
- Klinik für Innere Medizin, Pneumologie und Intensivmedizin, Evangelisches Klinikum Bethel, Universitätsklinikum Ost Westphalen-Lippe, Bielefeld
| | | | - Stephan Walterspacher
- Medizinische Klinik - Sektion Pneumologie, Klinikum Konstanz und Lehrstuhl für Pneumologie, Universität Witten-Herdecke, Witten
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Lehrstuhl für Pneumologie Universität Witten/Herdecke, Köln
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Baloglu O, Flagg LK, Suleiman A, Gupta V, Fast JA, Wang L, Worley S, Agarwal HS. Association of Fluid Overload with Escalation of Respiratory Support and Endotracheal Intubation in Acute Bronchiolitis Patients. J Pediatr Intensive Care 2024; 13:7-17. [PMID: 38571992 PMCID: PMC10987226 DOI: 10.1055/s-0041-1735873] [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: 05/06/2021] [Accepted: 08/05/2021] [Indexed: 10/20/2022] Open
Abstract
Fluid overload has been associated with increased oxygen requirement, prolonged duration of mechanical ventilation, and longer length of hospital stay in children hospitalized with pulmonary diseases. Critically ill infants with bronchiolitis admitted to the pediatric intensive care unit (PICU) also tend to develop fluid overload and there is limited information of its role on noninvasive respiratory support. Thus, our primary objective was to study the association of fluid overload in patients with bronchiolitis admitted to the PICU with respiratory support escalation (RSE) and need for endotracheal intubation (ETI). Infants ≤24 months of age with bronchiolitis and admitted to the PICU between 9/2009 and 6/2015 were retrospectively studied. Demographic variables, clinical characteristics including type of respiratory support and need for ETI were evaluated. Fluid overload as assessed by net fluid intake and output (net fluid balance), cumulative fluid balance (CFB) (mL/kg), and percentage fluid overload (FO%), was compared between patients requiring and not requiring RSE and among patients requiring ETI and not requiring ETI at 0 (PICU admission), 12, 24, 36, 48, 72, 96, and 120 hours. One-hundred sixty four of 283 patients with bronchiolitis admitted to the PICU qualified for our study. Thirty-four of 164 (21%) patients required escalation of respiratory support within 5 days of PICU admission and of these 34 patients, 11 patients required ETI. Univariate analysis by Kruskal-Wallis test of fluid overload as assessed by net fluid balance, CFB, and FO% between 34 patients requiring and 130 patients not requiring RSE and among 11 patients requiring ETI and 153 patients not requiring ETI, at 0, 12, 24, 36, 48, 72, 96 and 120 hours did not reveal any significant difference ( p >0.05) at any time interval. Multivariable logistic regression analysis revealed higher PRISM score (odds ratio [OR]: 4.95, 95% confidence interval [95% CI]: 1.79-13.66; p = 0.002), longer hours on high flow nasal cannula (OR: 4.86, 95% CI: 1.68-14.03; p = 0.003) and longer hours on noninvasive ventilation (OR: 11.16, 95% CI: 3.36-36.98; p < 0.001) were associated with RSE. Fluid overload as assessed by net fluid balance, CFB, and FO% was not associated with RSE or need for ETI in critically ill bronchiolitis patients admitted to the PICU. Further prospective studies involving larger number of patients with bronchiolitis are needed to corroborate our findings.
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Affiliation(s)
- Orkun Baloglu
- Department of Pediatric Critical Care Medicine, Cleveland Clinic Childreǹs, Cleveland, Ohio, United States
| | - Lauren K. Flagg
- Department of Pediatric Critical Care Medicine, Cleveland Clinic Childreǹs, Cleveland, Ohio, United States
| | - Ahmad Suleiman
- Department of Pediatric Critical Care Medicine, Cleveland Clinic Childreǹs, Cleveland, Ohio, United States
| | - Vedant Gupta
- Department of Pediatric Critical Care Medicine, Cleveland Clinic Childreǹs, Cleveland, Ohio, United States
| | - Jamie A. Fast
- Department of Pediatric Critical Care Medicine, Cleveland Clinic Childreǹs, Cleveland, Ohio, United States
| | - Lu Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, United States
| | - Sarah Worley
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, United States
| | - Hemant S. Agarwal
- Department of Pediatric Critical Care Medicine, Cleveland Clinic Childreǹs, Cleveland, Ohio, United States
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5
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D'Alessandro M, Fricano C, Abdulsatar F, Bechard N, Brar JS, Drouin O, Foulds JL, Giglia L, Gill PJ, Gupta R, Li P, McConnery J, Metcalf J, Sakran M, Seaton C, Sehgal A, Sirizzotti N, Mbuagbaw L, Wahi G. Understanding the use and outcomes of high-flow nasal cannula among infants admitted to Canadian hospitals with bronchiolitis (CanFLO): a protocol for a multicentre, retrospective cohort study. BMJ Open 2024; 14:e080197. [PMID: 38326253 PMCID: PMC10860006 DOI: 10.1136/bmjopen-2023-080197] [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: 09/23/2023] [Accepted: 01/24/2024] [Indexed: 02/09/2024] Open
Abstract
INTRODUCTION Bronchiolitis is the most common viral lower respiratory tract infection in children under 2 years of age. Respiratory support with high-flow nasal cannula (HFNC) is increasingly used in this patient population with limited understanding of the patients most likely to benefit and considerable practice variability of use. This study aims to understand the factors associated with failure of HFNC support among patients with bronchiolitis and to describe the current practice variations of HFNC use in patients with bronchiolitis in Canadian hospitals including fluid management and parameters to initiate, escalate and discontinue HFNC support. METHODS AND ANALYSIS This is a multicentre retrospective cohort study including hospitalised patients aged 0-24 months with bronchiolitis requiring support with HFNC between January 2017 and December 2021. Clinical data will be collected from patient medical records from Canadian hospitals (n=12), including academic and community centres. HFNC failure will be defined as the need for escalation to non-invasive or invasive mechanical ventilation. Factors associated with HFNC failure will be analysed using logistic regression. Descriptive statistics will be used to describe practice variations of HFNC utilisation and management. ETHICS AND DISSEMINATION Approval from the Research Ethics Boards (REBs) has been obtained for each participating study site prior to onset of data collection including Clinical Trials Ontario for all Ontario hospital sites and REBs from British Columbia Children's Hospital, Stollery Children's Hospital, Montreal Children's Hospital and CHU Sainte-Justine. Study results will be disseminated through presentation at national/international conferences and publication in high-impact, peer-reviewed journals.
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Affiliation(s)
| | - Chiara Fricano
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Farah Abdulsatar
- Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Nicole Bechard
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Jagraj Singh Brar
- Children's Hospital at London Health Sciences Centre, London, Ontario, Canada
| | - Olivier Drouin
- Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Jessica L Foulds
- Department of Pediatrics, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Lucia Giglia
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Peter J Gill
- Department of Paediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ronish Gupta
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Patricia Li
- Pediatrics, McGill University, Montreal, Quebec, Canada
| | | | | | - Mahmoud Sakran
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
- Lakeridge Health Oshawa Hospital, Oshawa, Ontario, Canada
| | - Claire Seaton
- BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Anupam Sehgal
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
- Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | | | - Lawrence Mbuagbaw
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Gita Wahi
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- McMaster Children's Hospital, Hamilton, Ontario, Canada
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McCluskey CK, Black TR, Zee-Cheng J, Klein MJ, Lin A, Rogerson CM, Carroll CL, Remy KE, Scanlon MC, Shein SL, Wright M, Rotta AT. Suicide and Self-Harm in Adolescents During the COVID-19 Pandemic: A U.S. Virtual Pediatric Systems, LLC, Database Study of PICU Admissions, 2016-2021. Pediatr Crit Care Med 2024; 25:e73-e81. [PMID: 37812055 DOI: 10.1097/pcc.0000000000003381] [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] [Indexed: 10/10/2023]
Abstract
OBJECTIVES To characterize the epidemiology of suicide and self-harm among adolescents admitted to PICUs during the first 2 years of the COVID-19 pandemic in the United States. DESIGN Descriptive analysis of a large, multicenter, quality-controlled database (Virtual Pediatric Systems [VPS]), and of a national public health dataset (U.S. Centers for Disease Control and Prevention web-based Wide-ranging ONline Data for Epidemiology Research [CDC WONDER]). SETTING The 69 PICUs participating in the VPS database that contributed data for the entire the study period, January 1, 2016, to December 31, 2021. PATIENTS Adolescents older than 12 years to younger than 18 years old admitted to a participating PICU during the study period with a diagnosis involving self-harm or a suicide attempt (VPS sample), or adolescent suicide deaths over the same period (CDC WONDER sample). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified 10,239 suicide deaths and 7,692 PICU admissions for self-harm, including 5,414 admissions in the pre-pandemic period (Q1-2016 to Q1-2020) and 2,278 in the pandemic period (Q2-2020 to Q4-2021). Compared with the pre-pandemic period, there was no increase in the median (interquartile range) number of suicide deaths per quarter (429 [399-453] vs. 416 [390-482]) or PICU admissions for self-harm per quarter (315 [289-353] vs. 310 [286-387]) during the pandemic period, respectively. There was an increase in the ratio of self-harm PICU admissions to all-cause PICU admissions per quarter during the pandemic (1.98 [1.43-2.12]) compared with the pre-pandemic period per quarter (1.59 [1.46-1.74]). We also observed a significant decrease in all-cause PICU admissions per quarter early in the pandemic compared with the pre-pandemic period (16,026 [13,721-16,297] vs. 19,607 [18,371-20,581]). CONCLUSIONS The number of suicide deaths and PICU admissions per quarter for self-harm remained relatively constant during the pandemic, while the number of all-cause PICU admissions per quarter decreased compared with the pre-pandemic period. The resultant higher ratio of self-harm admissions to all-cause PICU admissions may have contributed to the perception that more adolescents required critical care for mental health-related conditions early in the pandemic.
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Affiliation(s)
- Casey K McCluskey
- Department of Pediatrics, West Virginia University School of Medicine, Morgantown, WV
| | - Tyler R Black
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | | | - Margaret J Klein
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Anna Lin
- Department of Pediatrics, Stanford University, Palo Alto, CA
| | - Colin M Rogerson
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Christopher L Carroll
- Department of Pediatrics, University of Florida, Wolfson Children's Hospital, Jacksonville, FL
| | - Kenneth E Remy
- Department of Pediatrics, Case Western University School of Medicine, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Matthew C Scanlon
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Steven L Shein
- Department of Pediatrics, Case Western University School of Medicine, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Melvin Wright
- Department of Pediatrics, West Virginia University School of Medicine, Morgantown, WV
| | - Alexandre T Rotta
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
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Maue DK, Ealy A, Hobson MJ, Peterson RJ, Pike F, Nitu ME, Tori AJ, Abu-Sultaneh S. Improving Outcomes for Bronchiolitis Patients After Implementing a High-Flow Nasal Cannula Holiday and Standardizing Discharge Criteria in a PICU. Pediatr Crit Care Med 2023; 24:233-242. [PMID: 36645273 DOI: 10.1097/pcc.0000000000003183] [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] [Indexed: 01/17/2023]
Abstract
OBJECTIVES To decrease length of high-flow nasal cannula (HFNC), PICU, and hospital length of stay (LOS). DESIGN Quality improvement project. SETTING A quaternary academic PICU. PATIENTS Patients with bronchiolitis less than 24 months old. INTERVENTIONS After initial implementation of a respiratory therapist (RT)-driven HFNC protocol (Plan-Do-Study-Act [PDSA] 1) in October 2017, additional interventions included adjusting HFNC wean rate (PDSA 2) in July 2020, a HFNC holiday (PDSA 3), and standardized discharge criteria (PDSA 4) in October 2021. MEASUREMENTS AND MAIN RESULTS Duration of HFNC was used as the primary outcome measure. PICU LOS and hospital LOS were used as secondary outcome measures. Noninvasive ventilation use, invasive mechanical ventilation use, and 7-day PICU and hospital readmission rates were used as balancing measures. A total of 1,310 patients were included in this study. Patients in PDSA 2, PDSA 3 and 4 groups were older compared with pre-intervention and PDSA 1 (median of 9 and 10 mo compared with 8 mo; p = 0.01). HFNC duration decreased from 2.5 to 1.8 days after PDSA 1, then to 1.3 days after PDSA 2. PICU LOS decreased from 2.6 to 2.1 days after PDSA 1, 1.8 days after PDSA 2, and 1.5 days after PDSA 3 and 4. Hospital LOS decreased from 5.7 to 4.5 days after PDSA 1, 3.1 days after PDSA 2, and 2.7 days after PDSA 3 and 4. The use of noninvasive ventilation and invasive mechanical ventilation decreased throughout the study from 23.2% in the pre-intervention group, to 6.9% at the end of the project. The 7-day PICU and hospital readmission rates did not increase after implementation. The percentage of patients discharged from the PICU increased from 6.2% to 21.5%. CONCLUSIONS Modifications to an existing RT-driven HFNC protocol and standardization of discharge criteria led to an improvement in outcomes for patients admitted to the PICU with bronchiolitis without an increase in adverse events.
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Affiliation(s)
- Danielle K Maue
- Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Indianapolis, IN
| | - Aimee Ealy
- Department of Respiratory Care Services, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Michael J Hobson
- Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Indianapolis, IN
| | - Rachel J Peterson
- Department of Pediatrics, Division of Hospital Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Francis Pike
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN
| | - Mara E Nitu
- Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Indianapolis, IN
| | - Alvaro J Tori
- Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Indianapolis, IN
| | - Samer Abu-Sultaneh
- Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Indianapolis, IN
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8
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Huang JX, Colwell B, Vadlaputi P, Sauers-Ford H, Smith BJ, McKnight H, Witkowski J, Padovani A, Aghamohammadi S, Tzimenatos L, Beck S, Reneau K, Nill B, Harbour D, Pegadiotes J, Natale J, Hamline M, Siefkes H. Protocol-Driven Initiation and Weaning of High-Flow Nasal Cannula for Patients With Bronchiolitis: A Quality Improvement Initiative. Pediatr Crit Care Med 2023; 24:112-122. [PMID: 36661418 PMCID: PMC9869459 DOI: 10.1097/pcc.0000000000003136] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Bronchiolitis is the most common cause for nonelective infant hospitalization in the United States with increasing utilization of high-flow nasal cannula (HFNC). We standardized initiation and weaning of HFNC for bronchiolitis and quantified the impact on outcomes. Our specific aim was to reduce hospital and ICU length of stay (LOS) by 10% between two bronchiolitis seasons after implementation. DESIGN A quality improvement (QI) project using statistical process control methodology. SETTING Tertiary-care children's hospital with 24 PICU and 48 acute care pediatric beds. PATIENTS Children less than 24 months old with bronchiolitis without other respiratory diagnoses or underlying cardiac, respiratory, or neuromuscular disorders between December 2017 and November 2018 (baseline), and December 2018 and February 2020 (postintervention). INTERVENTIONS Interventions included development of an HFNC protocol with initiation and weaning guidelines, modification of protocol and respiratory assessment classification, education, and QI rounds with a focus on efficient HFNC weaning, transfer, and/or discharge. MEASUREMENTS AND MAIN RESULTS A total of 223 children were included (96 baseline and 127 postintervention). The primary outcome metric, average LOS per patient, decreased from 4.0 to 2.8 days, and the average ICU LOS per patient decreased from 2.8 to 1.9 days. The secondary outcome metric, average HFNC treatment hours per patient, decreased from 44.0 to 36.3 hours. The primary and secondary outcomes met criteria for special cause variation. Balancing measures included ICU readmission rates, 30-day readmission rates, and adverse events, which were not different between the two periods. CONCLUSIONS A standardized protocol for HFNC management for patients with bronchiolitis was associated with decreased hospital and ICU LOS, less time on HFNC, and no difference in readmissions or adverse events.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Shelli Beck
- University of California Davis Children’s Hospital
| | | | - Barbara Nill
- University of California Davis Children’s Hospital
| | - Dawn Harbour
- University of California Davis Children’s Hospital
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High-Flow Oxygen and Other Noninvasive Respiratory Support Therapies in Bronchiolitis: Systematic Review and Network Meta-Analyses. Pediatr Crit Care Med 2023; 24:133-142. [PMID: 36661419 DOI: 10.1097/pcc.0000000000003139] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES We present a systematic review on the effectiveness of noninvasive respiratory support techniques in bronchiolitis. DATA SOURCES Systematic review with pairwise meta-analyses of all studies and network meta-analyses of the clinical trials. STUDY SELECTION Patients below 24 months old with bronchiolitis who require noninvasive respiratory support were included in randomized controlled trials (RCTs), non-RCT, and cohort studies in which high-flow nasal cannula (HFNC) was compared with conventional low-flow oxygen therapy (LFOT) and/or noninvasive ventilation (NIV). DATA EXTRACTION Emergency wards and hospitalized patients with bronchiolitis. DATA SYNTHESIS A total of 3,367 patients were analyzed in 14 RCTs and 8,385 patients in 14 non-RCTs studies. Only in nonexperimental studies, HFNC is associated with a lower risk of invasive mechanical ventilation (MV) than NIV (odds ratio, 0.49; 95% CI, 0.42-0.58), with no differences in experimental studies. There were no differences between HFNC and NIV in other outcomes. HFNC is more effective than LFOT in reducing oxygen days and treatment failure. In the network meta-analyses of clinical trials, NIV was the most effective intervention to avoid invasive MV (surface under the cumulative ranking curve [SUCRA], 57.03%) and to reduce days under oxygen therapy (SUCRA, 79.42%), although crossover effect estimates between interventions showed no significant differences. The included studies show methodological heterogeneity, but it is only statistically significant for the reduction of days of oxygen therapy and length of hospital stay. CONCLUSIONS Experimental evidence does not suggest that high-flow oxygen therapy has advantages over LFOT as initial treatment nor over NIV as a rescue treatment.
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10
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Milési C, Baudin F, Durand P, Emeriaud G, Essouri S, Pouyau R, Baleine J, Beldjilali S, Bordessoule A, Breinig S, Demaret P, Desprez P, Gaillard-Leroux B, Guichoux J, Guilbert AS, Guillot C, Jean S, Levy M, Noizet-Yverneau O, Rambaud J, Recher M, Reynaud S, Valla F, Radoui K, Faure MA, Ferraro G, Mortamet G. Clinical practice guidelines: management of severe bronchiolitis in infants under 12 months old admitted to a pediatric critical care unit. Intensive Care Med 2023; 49:5-25. [PMID: 36592200 DOI: 10.1007/s00134-022-06918-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/13/2022] [Indexed: 01/03/2023]
Abstract
PURPOSE We present guidelines for the management of infants under 12 months of age with severe bronchiolitis with the aim of creating a series of pragmatic recommendations for a patient subgroup that is poorly individualized in national and international guidelines. METHODS Twenty-five French-speaking experts, all members of the Groupe Francophone de Réanimation et Urgence Pédiatriques (French-speaking group of paediatric intensive and emergency care; GFRUP) (Algeria, Belgium, Canada, France, Switzerland), collaborated from 2021 to 2022 through teleconferences and face-to-face meetings. The guidelines cover five areas: (1) criteria for admission to a pediatric critical care unit, (2) environment and monitoring, (3) feeding and hydration, (4) ventilatory support and (5) adjuvant therapies. The questions were written in the Patient-Intervention-Comparison-Outcome (PICO) format. An extensive Anglophone and Francophone literature search indexed in the MEDLINE database via PubMed, Web of Science, Cochrane and Embase was performed using pre-established keywords. The texts were analyzed and classified according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. When this method did not apply, an expert opinion was given. Each of these recommendations was voted on by all the experts according to the Delphi methodology. RESULTS This group proposes 40 recommendations. The GRADE methodology could be applied for 17 of them (3 strong, 14 conditional) and an expert opinion was given for the remaining 23. All received strong approval during the first round of voting. CONCLUSION These guidelines cover the different aspects in the management of severe bronchiolitis in infants admitted to pediatric critical care units. Compared to the different ways to manage patients with severe bronchiolitis described in the literature, our original work proposes an overall less invasive approach in terms of monitoring and treatment.
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Affiliation(s)
- Christophe Milési
- Pediatric Intensive Care Unit, Montpellier University Hospital, Montpellier, France.
| | - Florent Baudin
- Pediatric Intensive Care Unit, Lyon Hospital Femme-Mère-Enfants, Bron, France
| | - Philippe Durand
- Pediatric Intensive Care Unit, Bicêtre Hospital, Assistance Publique des Hôpitaux de Paris, Kremlin-Bicêtre, France
| | - Guillaume Emeriaud
- Pediatric Intensive Care Unit, Sainte-Justine University Hospital, Montreal, Canada
| | - Sandrine Essouri
- Pediatric Department, Sainte-Justine University Hospital, Montreal, Canada
| | - Robin Pouyau
- Pediatric Intensive Care Unit, Lyon Hospital Femme-Mère-Enfants, Bron, France
| | - Julien Baleine
- Pediatric Intensive Care Unit, Montpellier University Hospital, Montpellier, France
| | - Sophie Beldjilali
- Pediatric Intensive Care Unit, La Timone University Hospital, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Alice Bordessoule
- Pediatric Intensive Care Unit, Geneva University Hospital, Geneva, Switzerland
| | - Sophie Breinig
- Pediatric Intensive Care Unit, Toulouse University Hospital, Toulouse, France
| | - Pierre Demaret
- Intensive Care Unit, Liège University Hospital, Liège, Belgium
| | - Philippe Desprez
- Pediatric Intensive Care Unit, Point-à-Pitre University Hospital, Point-à-Pitre, France
| | | | - Julie Guichoux
- Pediatric Intensive Care Unit, Bordeaux University Hospital, Bordeaux, France
| | - Anne-Sophie Guilbert
- Pediatric Intensive Care Unit, Strasbourg University Hospital, Strasbourg, France
| | - Camille Guillot
- Pediatric Intensive Care Unit, Lille University Hospital, Lille, France
| | - Sandrine Jean
- Pediatric Intensive Care Unit, Trousseau Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Michael Levy
- Pediatric Intensive Care Unit, Robert Debré Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | | | - Jérôme Rambaud
- Pediatric Intensive Care Unit, Trousseau Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Morgan Recher
- Pediatric Intensive Care Unit, Lille University Hospital, Lille, France
| | - Stéphanie Reynaud
- Pediatric Intensive Care Unit, Lyon Hospital Femme-Mère-Enfants, Bron, France
| | - Fréderic Valla
- Pediatric Intensive Care Unit, Lyon Hospital Femme-Mère-Enfants, Bron, France
| | - Karim Radoui
- Pneumology EHS Pediatric Department, Faculté de Médecine d'Oran, Canastel, Oran, Algeria
| | | | - Guillaume Ferraro
- Pediatric Emergency Department, Nice University Hospital, Nice, France
| | - Guillaume Mortamet
- Pediatric Intensive Care Unit, Grenoble-Alpes University Hospital, Grenoble, France
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Commentary on the First-Line Support for Assistance in Breathing in Children Trials on Noninvasive Respiratory Support: Taking a Closer Look. Pediatr Crit Care Med 2022; 23:1084-1088. [PMID: 36305663 DOI: 10.1097/pcc.0000000000003096] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Noninvasive respiratory support modalities such as high-flow nasal cannula (HFNC) therapy and continuous positive airway pressure (CPAP) are used frequently in pediatric critical care to support acutely ill children with respiratory failure (step-up management) and children following extubation (step-down management). Although there are several observational studies and database analyses comparing the efficacy of HFNC and CPAP, and a few small randomized clinical trials (RCTs), until recently, there were no large RCTs comparing the two modalities in a mixed group of critically ill children. In the first half of 2022, results from the First-Line Support for Assistance in Breathing in Children (FIRST-ABC) trials were published; these comprised a master protocol of two trials: one in acutely ill children (step-up RCT) and one in extubated children (step-down RCT). Each of these pragmatic trials randomized 600 children to either HFNC or CPAP when the treating clinician decided that noninvasive respiratory support beyond standard oxygen therapy was required. The primary outcome was time to liberation from all forms of respiratory support (invasive and noninvasive), excluding supplemental oxygen. The FIRST-ABC trials represent a significant advance in the field of noninvasive respiratory support, which has traditionally been evidence-poor and associated with considerable variability in clinical practice. In this article, we provide an overview of how the FIRST-ABC trials were conceived and conducted, our view on the results, and how the trial findings have changed our clinical practice.
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12
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Commentary on High-Flow Nasal Cannula and Continuous Positive Airway Pressure Practices After the First-Line Support for Assistance in Breathing in Children Trials. Pediatr Crit Care Med 2022; 23:1076-1083. [PMID: 36250746 DOI: 10.1097/pcc.0000000000003097] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Continuous positive airway pressure (CPAP) and heated humidified high-flow nasal cannula (HFNC) are commonly used to treat children admitted to the PICU who require more respiratory support than simple oxygen therapy. Much has been published on these two treatment modalities over the past decade, both in Pediatric Critical Care Medicine (PCCM ) and elsewhere. The majority of these studies are observational analyses of clinical, administrative, or quality improvement datasets and, therefore, are only able to establish associations between exposure to treatment and outcomes, not causation. None of the initial randomized clinical trials comparing HFNC and CPAP were definitive due to their relatively small sample sizes with insufficient power for meaningful clinical outcomes (e.g., escalation to bilevel noninvasive ventilation or intubation, duration of PICU-level respiratory support, mortality) and often yielded ambiguous findings or conflicting results. The recent publication of the First-Line Support for Assistance in Breathing in Children (FIRST-ABC) trials represented a major step toward understanding the role of CPAP and HFNC use in critically ill children. These large, pragmatic, randomized clinical trials examined the efficacy of CPAP and HFNC either for "step up" (i.e., escalation in respiratory support) during acute respiratory deterioration or for "step down" (i.e., postextubation need for respiratory support) management. This narrative review examines the body of evidence on HFNC published in PCCM , contextualizes the findings of randomized clinical trials of CPAP and HFNC up to and including the FIRST-ABC trials, provides guidance to PICU clinicians on how to implement the literature in current practice, and discusses remaining knowledge gaps and future research priorities.
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13
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Ramnarayan P, Richards-Belle A, Drikite L, Saull M, Orzechowska I, Darnell R, Sadique Z, Lester J, Morris KP, Tume LN, Davis PJ, Peters MJ, Feltbower RG, Grieve R, Thomas K, Mouncey PR, Harrison DA, Rowan KM. Effect of High-Flow Nasal Cannula Therapy vs Continuous Positive Airway Pressure Therapy on Liberation From Respiratory Support in Acutely Ill Children Admitted to Pediatric Critical Care Units: A Randomized Clinical Trial. JAMA 2022; 328:162-172. [PMID: 35707984 PMCID: PMC9204623 DOI: 10.1001/jama.2022.9615] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
IMPORTANCE The optimal first-line mode of noninvasive respiratory support for acutely ill children is not known. OBJECTIVE To evaluate the noninferiority of high-flow nasal cannula therapy (HFNC) as the first-line mode of noninvasive respiratory support for acute illness, compared with continuous positive airway pressure (CPAP), for time to liberation from all forms of respiratory support. DESIGN, SETTING, AND PARTICIPANTS Pragmatic, multicenter, randomized noninferiority clinical trial conducted in 24 pediatric critical care units in the United Kingdom among 600 acutely ill children aged 0 to 15 years who were clinically assessed to require noninvasive respiratory support, recruited between August 2019 and November 2021, with last follow-up completed in March 2022. INTERVENTIONS Patients were randomized 1:1 to commence either HFNC at a flow rate based on patient weight (n = 301) or CPAP of 7 to 8 cm H2O (n = 299). MAIN OUTCOMES AND MEASURES The primary outcome was time from randomization to liberation from respiratory support, defined as the start of a 48-hour period during which a participant was free from all forms of respiratory support (invasive or noninvasive), assessed against a noninferiority margin of an adjusted hazard ratio of 0.75. Seven secondary outcomes were assessed, including mortality at critical care unit discharge, intubation within 48 hours, and use of sedation. RESULTS Of the 600 randomized children, consent was not obtained for 5 (HFNC: 1; CPAP: 4) and respiratory support was not started in 22 (HFNC: 5; CPAP: 17); 573 children (HFNC: 295; CPAP: 278) were included in the primary analysis (median age, 9 months; 226 girls [39%]). The median time to liberation in the HFNC group was 52.9 hours (95% CI, 46.0-60.9 hours) vs 47.9 hours (95% CI, 40.5-55.7 hours) in the CPAP group (absolute difference, 5.0 hours [95% CI -10.1 to 17.4 hours]; adjusted hazard ratio 1.03 [1-sided 97.5% CI, 0.86-∞]). This met the criterion for noninferiority. Of the 7 prespecified secondary outcomes, 3 were significantly lower in the HFNC group: use of sedation (27.7% vs 37%; adjusted odds ratio, 0.59 [95% CI, 0.39-0.88]); mean duration of critical care stay (5 days vs 7.4 days; adjusted mean difference, -3 days [95% CI, -5.1 to -1 days]); and mean duration of acute hospital stay (13.8 days vs 19.5 days; adjusted mean difference, -7.6 days [95% CI, -13.2 to -1.9 days]). The most common adverse event was nasal trauma (HFNC: 6/295 [2.0%]; CPAP: 18/278 [6.5%]). CONCLUSIONS AND RELEVANCE Among acutely ill children clinically assessed to require noninvasive respiratory support in a pediatric critical care unit, HFNC compared with CPAP met the criterion for noninferiority for time to liberation from respiratory support. TRIAL REGISTRATION ISRCTN.org Identifier: ISRCTN60048867.
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Affiliation(s)
- Padmanabhan Ramnarayan
- Section of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, England
- Children’s Acute Transport Service, Great Ormond Street Hospital for Children NHS Foundation Trust, London, England
| | - Alvin Richards-Belle
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Laura Drikite
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Michelle Saull
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Izabella Orzechowska
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Robert Darnell
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, England
| | | | - Kevin P. Morris
- Birmingham Children’s Hospital, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, England
- Institute of Applied Health Research, University of Birmingham, Birmingham, England
| | - Lyvonne N. Tume
- School of Health and Society, University of Salford, Salford, England
| | - Peter J. Davis
- Paediatric Intensive Care Unit, Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, England
| | - Mark J. Peters
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, England
- University College London Great Ormond Street Institute of Child Health, London, England
| | - Richard G. Feltbower
- Leeds Institute for Data Analytics, School of Medicine, University of Leeds, Leeds, England
| | - Richard Grieve
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, England
| | - Karen Thomas
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Paul R. Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - David A. Harrison
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Kathryn M. Rowan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
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14
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Leboucher J, Milési C, Fumagalli A, Wroblewski I, Debillon T, Mortamet G. Prevalence and risk factors of discomfort in infants with severe bronchiolitis. Acta Paediatr 2022; 111:1238-1244. [PMID: 35181910 DOI: 10.1111/apa.16305] [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: 12/09/2021] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 11/27/2022]
Abstract
AIM The aim of this study was to assess the prevalence of discomfort in infants with severe bronchiolitis supported by noninvasive ventilation and to identify its potential risk factors. METHODS A single-centre retrospective observational study. Discomfort was assessed using the EDIN (Echelle de Douleur et d'Inconfort du Nouveau-né) scale. RESULTS Ninety-one infants (median age 34 days [Interquartile IQR 19-55], 52 (57%) boys) were included in our study. Overall, no patient had a mean EDIN score higher than 8 on Days 1, 2 and 3. On Days 1 and 2, patients supported by bilevel positive airway pressure (BiPAP) had a higher EDIN score compared with other patients (3.3 [SD 2.5] versus 2.6 [SD 2.2] on Day 1 and 2.9 (SD 2.1) versus 2.3 (SD 2.2) on Day 2, both p < 0.001). CONCLUSION Patients with severe bronchiolitis and supported by any type of noninvasive ventilation had a low degree of discomfort during the first 3 days of ICU stay. Patients requiring bilevel noninvasive ventilation appeared to have a higher degree of discomfort, while we found no correlation between the level of discomfort and the degree of respiratory distress.
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Affiliation(s)
- Justine Leboucher
- Pediatric Intensive Care Unit Grenoble‐Alpes University Hospital Grenoble France
| | - Christophe Milési
- Pediatric Intensive Care Unit Montpellier University Hospital Montpellier France
| | - Alice Fumagalli
- Pediatric Intensive Care Unit Grenoble‐Alpes University Hospital Grenoble France
| | - Isabelle Wroblewski
- Pediatric Intensive Care Unit Grenoble‐Alpes University Hospital Grenoble France
| | - Thierry Debillon
- Neonatal Intensive Care Unit Grenoble‐Alpes University Hospital Grenoble France
| | - Guillaume Mortamet
- Pediatric Intensive Care Unit Grenoble‐Alpes University Hospital Grenoble France
- Univ. Grenoble‐Alpes Grenoble France
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Lindell RB, Fitzgerald JC, Rowan CM, Flori HR, Di Nardo M, Napolitano N, Traynor DM, Lenz KB, Emeriaud G, Jeyapalan A, Nishisaki A. The Use and Duration of Preintubation Respiratory Support Is Associated With Increased Mortality in Immunocompromised Children With Acute Respiratory Failure. Crit Care Med 2022; 50:1127-1137. [PMID: 35275593 PMCID: PMC9707852 DOI: 10.1097/ccm.0000000000005535] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine the association between preintubation respiratory support and outcomes in patients with acute respiratory failure and to determine the impact of immunocompromised (IC) diagnoses on outcomes after adjustment for illness severity. DESIGN Retrospective multicenter cohort study. SETTING Eighty-two centers in the Virtual Pediatric Systems database. PATIENTS Children 1 month to 17 years old intubated in the PICU who received invasive mechanical ventilation (IMV) for greater than or equal to 24 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS High-flow nasal cannula (HFNC) or noninvasive positive-pressure ventilation (NIPPV) or both were used prior to intubation in 1,825 (34%) of 5,348 PICU intubations across 82 centers. When stratified by IC status, 50% of patients had no IC diagnosis, whereas 41% were IC without prior hematopoietic cell transplant (HCT) and 9% had prior HCT. Compared with patients intubated without prior support, preintubation exposure to HFNC (adjusted odds ratio [aOR], 1.33; 95% CI, 1.10-1.62) or NIPPV (aOR, 1.44; 95% CI, 1.20-1.74) was associated with increased odds of PICU mortality. Within subgroups of IC status, preintubation respiratory support was associated with increased odds of PICU mortality in IC patients (HFNC: aOR, 1.50; 95% CI, 1.11-2.03; NIPPV: aOR, 1.76; 95% CI, 1.31-2.35) and HCT patients (HFNC: aOR, 1.75; 95% CI, 1.07-2.86; NIPPV: aOR, 1.85; 95% CI, 1.12-3.02) compared with IC/HCT patients intubated without prior respiratory support. Preintubation exposure to HFNC/NIPPV was not associated with mortality in patients without an IC diagnosis. Duration of HFNC/NIPPV greater than 6 hours was associated with increased mortality in IC HCT patients (HFNC: aOR, 2.41; 95% CI, 1.05-5.55; NIPPV: aOR, 2.53; 95% CI, 1.04-6.15) and patients compared HCT patients with less than 6-hour HFNC/NIPPV exposure. After adjustment for patient and center characteristics, both preintubation HFNC/NIPPV use (median, 15%; range, 0-63%) and PICU mortality varied by center. CONCLUSIONS In IC pediatric patients, preintubation exposure to HFNC and/or NIPPV is associated with increased odds of PICU mortality, independent of illness severity. Longer duration of exposure to HFNC/NIPPV prior to IMV is associated with increased mortality in HCT patients.
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Affiliation(s)
- Robert B Lindell
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. Division of Critical Care, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN. Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI. Pediatric Intensive Care Unit, Bambino Gesù, Children's Hospital, IRCCS, Rome, Italy. Department of Respiratory Therapy, Children's Hospital of Philadelphia, Philadelphia, PA. Department of Pediatrics, Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, Montreal, QC. Division of Pediatric Critical Care Medicine, University of Miami Miller School of Medicine, Miami, FL
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16
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Clayton JA, Slain KN, Shein SL, Cheifetz IM. High Flow Nasal Cannula in the Pediatric Intensive Care Unit. Expert Rev Respir Med 2022; 16:409-417. [PMID: 35240901 DOI: 10.1080/17476348.2022.2049761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The use of high flow nasal cannula (HFNC) has become widely used in pediatric intensive care units (PICUs) throughout the world. The rapid adoption has outpaced the number of studies evaluating the safety and efficacy in a variety of pediatric diseases/conditions. AREAS COVERED This scoping review begins with the definition and mechanisms of action of HFNC and then follows with a review of the literature focused on studies performed on critically ill children cared for in the PICU. The Pubmed database was searched with a pediatric filter from the time period 2000 to 2021. EXPERT OPINION The rapid adoption of HFNC in PICUs has largely been driven by changes in institutional practices and small observational studies. There is a lack of adequately powered studies evaluating patient-centered outcomes, such as intubation rates, mortality, PICU and hospital length of stay. Given the wide variability in flow rates and clinical indications, more research is needed to better define effective flow rates for different disease states as well as markers of treatment success and failure. One particular entity that is poorly studied is the use of HFNC in those at risk for developing pediatric acute respiratory distress syndrome (PARDS).
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Affiliation(s)
- Jason A Clayton
- Division of Pediatric Critical Care Medicine, Rainbow Babies & Children's Hospital, Cleveland, Ohio
| | - Katherine N Slain
- Division of Pediatric Critical Care Medicine, Rainbow Babies & Children's Hospital, Cleveland, Ohio
| | - Steven L Shein
- Division of Pediatric Critical Care Medicine, Rainbow Babies & Children's Hospital, Cleveland, Ohio
| | - Ira M Cheifetz
- Division of Pediatric Cardiac Critical Care Medicine, Rainbow Babies & Children's Hospital, Cleveland, Ohio
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Abstract
OBJECTIVES To evaluate the contribution of PICU care to increasing hospital charges for patients with bronchiolitis over a 10-year study period. DESIGN In this retrospective multicenter study, changes in annual hospital charges (adjusted for inflation) were analyzed using linear regression for subjects admitted to the PICU with invasive mechanical ventilation (PICU + IMV) and without IMV (PICU - IMV), and for children not requiring PICU care. SETTING Free-standing children's hospitals contributing to the Pediatric Health Information System (PHIS) database. SUBJECTS Children less than 2 years with bronchiolitis discharged from a PHIS hospital between July 2009 and June 2019. Subjects were categorized as high risk if they were born prematurely or had a chronic complex condition. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS PICU patients were 26.5% of the 283,006 included subjects but accrued 66% of the total $14.83 billion in charges. Annual charges increased from $1.01 billion in 2009-2010 to $2.07 billion in 2018-2019, and PICU patients accounted for 83% of this increase. PICU + IMV patients were 22% of all PICU patients and accrued 64% of all PICU charges, but PICU - IMV patients without a high-risk condition had the highest relative increase in annual charges, increasing from $76.7 million in 2009-2010 to $377.9 million in 2018-2019 (374% increase, ptrend < 0.001). CONCLUSIONS In a multicenter cohort study of children hospitalized with bronchiolitis, PICU patients, especially low-risk children without the need for IMV, were the highest driver of increased hospital charges over a 10-year study period.
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Affiliation(s)
- Katherine N Slain
- Department of Pediatrics, Division of Pediatric Critical Care, Rainbow Babies & Children's Hospital, Cleveland, OH
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Sindhoosha Malay
- Department of Pediatrics, Division of Pediatric Critical Care, Rainbow Babies & Children's Hospital, Cleveland, OH
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Steven L Shein
- Department of Pediatrics, Division of Pediatric Critical Care, Rainbow Babies & Children's Hospital, Cleveland, OH
- Case Western Reserve University School of Medicine, Cleveland, OH
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Safety and effectiveness of bubble continuous positive airway pressure as respiratory support for bronchiolitis in a pediatric ward. Eur J Pediatr 2022; 181:4039-4047. [PMID: 36129536 PMCID: PMC9649485 DOI: 10.1007/s00431-022-04616-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 08/20/2022] [Accepted: 09/05/2022] [Indexed: 12/02/2022]
Abstract
UNLABELLED The results of several clinical trials suggest that continuous positive airway pressure (CPAP) for acute bronchiolitis can be more effective than high-flow nasal cannula (HFNC). The use of HFNC involved a minimum reduction (5%) in admissions to the pediatric intensive care unit (PICU) in our hospital. Our main aim was to evaluate its safety and effectiveness as respiratory support for patients with bronchiolitis in a pediatric general ward. A secondary goal was to compare the admissions to PICU and the invasive mechanical ventilation (IMV) rate of patients treated with HFNC and those treated with HFNC/b-CPAP during the 2018-2019 and 2019-2020 epidemic seasons, respectively. Two prospective single-centre observational studies were performed. For the main aim, a cohort study (CS1) was carried out from 1st of November 2019 to 15th of January 2020. Inclusion criteria were children aged up to 3 months with bronchiolitis treated with b-CPAP support when HFNC failed. Epidemiological and clinical parameters were collected before and 60 min after the onset of CPAP and compared between the responder (R) and non-responders (NR) groups. NR was the group that required PICU admission. One hundred fifty-eight patients were admitted to the ward with bronchiolitis and HFNC. Fifty-seven out of one hundred fifty-eight required b-CPAP. No adverse events were observed. Thirty-two out of fifty-seven remained in the general ward (R-group), and 25/57 were admitted to PICU (NR-group). There were statistically significant differences in respiratory rate (RR) and heart rate (HR) between both groups before and after the initiation of b-CPAP, but the multivariable models showed that the main differences were observed after 60 min of therapy (lower HR, RR, BROSJOD score and FiO2 in the R-group). For the secondary aim, another cohort study (CS2) was performed comparing data from a pre-b-CPAP bronchiolitis season (1st of November 2018 to 15th January 2019) and the b-CPAP season (2019-2020). Inclusion criteria in pre-b-CPAP season were children aged up to 3 months admitted to the same general ward with moderate-severe bronchiolitis and with HFNC support. Admissions to PICU during the CPAP season were significantly reduced, without entailing an increase in the rate of IMV. CONCLUSION The implementation of b-CPAP for patients with bronchiolitis in a pediatric ward, in whom HFNC fails, is safe and effective and results in a reduction in PICU admissions. WHAT IS KNOWN • Bronchiolitis is one of the most frequent respiratory infections in children and one of the leading causes of hospitalization in infants. • Several studies suggest that the use of continuous positive airway pressure (CPAP) for acute bronchiolitis can be more effective than the high flow nasal cannula (HFNC). CPAP is a non-invasive ventilation (NIV) therapy used in patients admitted to pediatric intensive care unit (PICU) with progressive moderate-severe bronchiolitis. There is little experience in the literature on the use of continuous positive airway pressure (CPAP) for acute bronchiolitis in a general ward. WHAT IS NEW • CPAP could be safely and effectively used as respiratory support in young infants with moderate-severe bronchiolitis in a general ward and it reduced the rate of patients who required PICU admission. • Patients' heart and respiratory rate and their FiO2 needs in the first 60 minutes may help to decide whether or not to continue the CPAP therapy in a general ward.
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Abstract
OBJECTIVES To derive and internally validate a bronchiolitis-specific illness severity score (the Critical Bronchiolitis Score) that out-performs mortality-based illness severity scores (e.g., Pediatric Risk of Mortality) in measuring expected duration of respiratory support and PICU length of stay for critically ill children with bronchiolitis. DESIGN Retrospective database study using the Virtual Pediatric Systems (VPS, LLC; Los Angeles, CA) database. SETTING One-hundred twenty-eight North-American PICUs. PATIENTS Fourteen-thousand four-hundred seven children less than 2 years old admitted to a contributing PICU with primary diagnosis of bronchiolitis and use of ICU-level respiratory support (defined as high-flow nasal cannula, noninvasive ventilation, invasive mechanical ventilation, or negative pressure ventilation) at 12 hours after PICU admission. INTERVENTIONS Patient-level variables available at 12 hours from PICU admission, duration of ICU-level respiratory support, and PICU length of stay data were extracted for analysis. After randomly dividing the cohort into derivation and validation groups, patient-level variables that were significantly associated with the study outcomes were selected in a stepwise backward fashion for inclusion in the final score. Score performance in the validation cohort was assessed using root mean squared error and mean absolute error, and performance was compared with that of existing PICU illness severity scores. MEASUREMENTS AND MAIN RESULTS Twelve commonly available patient-level variables were included in the Critical Bronchiolitis Score. Outcomes calculated with the score were similar to actual outcomes in the validation cohort. The Critical Bronchiolitis Score demonstrated a statistically significantly stronger association with duration of ICU-level respiratory support and PICU length of stay than mortality-based scores as measured by root mean squared error and mean absolute error. CONCLUSIONS The Critical Bronchiolitis Score performed better than PICU mortality-based scores in measuring expected duration of ICU-level respiratory support and ICU length of stay. This score may have utility to enrich interventional trials and adjust for illness severity in observational studies in this very common PICU condition.
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Biggerstaff S, Markham JL, Winer JC, Richardson T, Berg KJ. Impact of High Flow Nasal Cannula on Resource Utilization in Bronchiolitis. Hosp Pediatr 2021:e2021005846. [PMID: 34957495 DOI: 10.1542/hpeds.2021-005846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES High flow nasal cannula (HFNC) is increasingly used for children hospitalized with bronchiolitis. We aimed to validate identification of HFNC use in a national database, then compare resource utilization among children treated with and without HFNC. METHODS In this cross-sectional, multicenter study, we obtained clinical and resource utilization data from the Pediatric Health Information System (PHIS) database for healthy children aged 1 to 24 months admitted for bronchiolitis. We assessed HFNC use based on a combination of billing codes and reviewed charts at 2 hospitals to determine their accuracy. We compared costs, length of stay, and readmissions between the HFNC and no HFNC groups at hospitals utilizing the HFNC codes. RESULTS The PHIS codes demonstrated 90.4% sensitivity and 99.3% specificity to detect HFNC use as verified by chart review at 2 hospitals. However, only 24 of 51 PHIS hospitals used these codes for ≥1% of patients with bronchiolitis. Within those hospitals, children treated with HFNC had greater total costs ($7054 vs $4544; P < .001), greater daily costs ($2922 vs $2613; P < .001), and longer length of stay (57.6 vs 41.6 hours; P < .001). Those treated with HFNC were less likely to be readmitted at 3 and 7 days (P < .001), but by 14 days, readmissions were similar in the 2 groups. CONCLUSIONS Billing codes for HFNC are inconsistently applied across PHIS hospitals; however, among those hospitals that routinely apply these codes, HFNC was associated with more intense resource utilization. Standardization of billing practices for HFNC would allow future study to more broadly describe the value of HFNC.
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Affiliation(s)
- Scott Biggerstaff
- Department of Pediatrics, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Jessica L Markham
- Department of Pediatrics, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
- Department of Pediatrics, University of Kansas School of Medicine, Kansas City, Kansas
| | - Jeffrey C Winer
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee; and
| | | | - Kathleen J Berg
- Department of Pediatrics, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
- Department of Pediatrics, University of Kansas School of Medicine, Kansas City, Kansas
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Angurana SK, Takia L, Sarkar S, Jangra I, Bora I, Ratho RK, Jayashree M. Clinico-virological Profile, Intensive Care Needs, and Outcome of Infants with Acute Viral Bronchiolitis: A Prospective Observational Study. Indian J Crit Care Med 2021; 25:1301-1307. [PMID: 34866830 PMCID: PMC8608649 DOI: 10.5005/jp-journals-10071-24016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES The objective of the study was to describe the clinico-virological profile, treatment details, intensive care needs, and outcome of infants with acute viral bronchiolitis (AVB). METHODOLOGY In this prospective observational study, 173 infants with AVB admitted to the pediatric emergency room and pediatric intensive care unit (PICU) of a tertiary care teaching hospital in North India during November 2019 to February 2020 were enrolled. The data collection included clinical features, viruses detected [respiratory syncytial virus (RSV), rhinovirus, influenza A virus, parainfluenza virus (PIV) 2 and 3, and human metapneumovirus (hMPV)], complications, intensive care needs, treatment, and outcomes. Multivariate analysis was performed to determine independent predictors for PICU admission. RESULTS Most common symptoms were rapid breathing (98.8%), cough (98.3%), and fever (74%). On examination, tachypnea (98.8%), chest retractions (93.6%), respiratory failure (84.4%), wheezing (49.7%), and crepitations (23.1%) were observed. RSV and rhinovirus were the predominant isolates. Complications were noted in 25% of cases as encephalopathy (17.3%), transaminitis (14.3%), shock (13.9%), acute kidney injury (AKI) (7.5%), myocarditis (6.4%), multiple organ dysfunction syndrome (MODS) (5.8%), and acute respiratory distress syndrome (ARDS) (4.6%). More than one-third of cases required PICU admission. The treatment details included nasal cannula oxygen (11%), continuous positive airway pressure (51.4%), high-flow nasal cannula (14.5%), mechanical ventilation (23.1%), nebulization (74%), antibiotics (35.9%), and vasoactive drugs (13.9%). The mortality was 8.1%. Underlying comorbidity, chest retractions, respiratory failure at admission, presence of shock, and need for mechanical ventilation were independent predictors of PICU admission. Isolation of virus or coinfection was not associated with disease severity, intensive care needs, and outcomes. CONCLUSION Among infants with AVB, RSV and rhinovirus were predominant. One-third infants with AVB needed PICU admission. The presence of comorbidity, chest retractions, respiratory failure, shock, and need for mechanical ventilation independently predicted PICU admission. HOW TO CITE THIS ARTICLE Angurana SK, Takia L, Sarkar S, Jangra I, Bora I, Ratho RK, et al. Clinico-virological Profile, Intensive Care Needs, and Outcome of Infants with Acute Viral Bronchiolitis: A Prospective Observational Study. Indian J Crit Care Med 2021;25(11):1301-1307.
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Affiliation(s)
| | - Lalit Takia
- Department of Pediatrics, PGIMER, Chandigarh, India
| | | | | | - Ishani Bora
- Department of Virology, PGIMER, Chandigarh, India
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Zee-Cheng JE, McCluskey CK, Klein MJ, Scanlon MC, Rotta AT, Shein SL, Pineda JA, Remy KE, Carroll CL. Changes in Pediatric ICU Utilization and Clinical Trends During the Coronavirus Pandemic. Chest 2021; 160:529-537. [PMID: 33727033 PMCID: PMC7954775 DOI: 10.1016/j.chest.2021.03.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Children have been less affected by the COVID-19 pandemic, but its repercussions on pediatric illnesses may have been significant. This study examines the indirect impact of the pandemic on a population of critically ill children in the United States. RESEARCH QUESTION Were there significantly fewer critically ill children admitted to PICUs during the second quarter of 2020, and were there significant changes in the types of diseases admitted? STUDY DESIGN AND METHODS This retrospective observational cohort study used the Virtual Pediatric Systems database. Participants were 160,295 children admitted to the PICU at 77 sites in the United States during quarters 1 (Q1) and 2 (Q2) of 2017 to 2019 (pre-COVID-19) and 2020 (COVID-19). RESULTS The average number of admissions was similar between pre-COVID-19 Q1 and COVID-19 Q1 but decreased by 32% from pre-COVID-19 Q2 to COVID-19 Q2 (20,157 to 13,627 admissions per quarter). The largest decreases were in respiratory conditions, including asthma (1,327 subjects in pre-COVID-19 Q2 (6.6% of patients) vs 241 subjects in COVID-19 Q2 (1.8%; P < .001) and bronchiolitis (1,299 [6.5%] vs 121 [0.9%]; P < .001). The percentage of trauma admissions increased, although the raw number of trauma admissions decreased. Admissions for diabetes mellitus and poisoning/ingestion also increased. In the multivariable model, illness severity-adjusted odds of ICU mortality for PICU patients during COVID-19 Q2 increased compared with pre-COVID-19 Q2 (OR, 1.165; 95% CI, 1.00-1.357; P = .049). INTERPRETATION Pediatric critical illness admissions decreased substantially during the second quarter of 2020, with significant changes in the types of diseases seen in PICUs in the United States. There was an increase in mortality in children admitted to the PICU during this period.
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Affiliation(s)
- Janine E Zee-Cheng
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN.
| | - Casey K McCluskey
- Department of Pediatrics, West Virginia University School of Medicine, Morgantown, WV
| | - Margaret J Klein
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Matthew C Scanlon
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Alexandre T Rotta
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Steven L Shein
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Jose A Pineda
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Kenneth E Remy
- Departments of Pediatrics and Internal Medicine, Washington University in St. Louis, St. Louis, MO
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Pappy G, Aczon M, Wetzel R, Ledbetter D. Predicting High-Flow Nasal Cannula Failure in an ICU Using a Recurrent Neural Network with Transfer Learning and Input Data Perseveration: A Retrospective Analysis (Preprint). JMIR Med Inform 2021; 10:e31760. [PMID: 35238792 PMCID: PMC8931642 DOI: 10.2196/31760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 12/10/2021] [Accepted: 01/03/2022] [Indexed: 12/03/2022] Open
Abstract
Background High flow nasal cannula (HFNC) provides noninvasive respiratory support for children who are critically ill who may tolerate it more readily than other noninvasive ventilation (NIV) techniques such as bilevel positive airway pressure and continuous positive airway pressure. Moreover, HFNC may preclude the need for mechanical ventilation (intubation). Nevertheless, NIV or intubation may ultimately be necessary for certain patients. Timely prediction of HFNC failure can provide an indication for increasing respiratory support. Objective The aim of this study is to develop and compare machine learning (ML) models to predict HFNC failure. Methods A retrospective study was conducted using the Virtual Pediatric Intensive Care Unit database of electronic medical records of patients admitted to a tertiary pediatric intensive care unit between January 2010 and February 2020. Patients aged <19 years, without apnea, and receiving HFNC treatment were included. A long short-term memory (LSTM) model using 517 variables (vital signs, laboratory data, and other clinical parameters) was trained to generate a continuous prediction of HFNC failure, defined as escalation to NIV or intubation within 24 hours of HFNC initiation. For comparison, 7 other models were trained: a logistic regression (LR) using the same 517 variables, another LR using only 14 variables, and 5 additional LSTM-based models using the same 517 variables as the first LSTM model and incorporating additional ML techniques (transfer learning, input perseveration, and ensembling). Performance was assessed using the area under the receiver operating characteristic (AUROC) curve at various times following HFNC initiation. The sensitivity, specificity, and positive and negative predictive values of predictions at 2 hours after HFNC initiation were also evaluated. These metrics were also computed for a cohort with primarily respiratory diagnoses. Results A total of 834 HFNC trials (455 [54.6%] training, 173 [20.7%] validation, and 206 [24.7%] test) met the inclusion criteria, of which 175 (21%; training: 103/455, 22.6%; validation: 30/173, 17.3%; test: 42/206, 20.4%) escalated to NIV or intubation. The LSTM models trained with transfer learning generally performed better than the LR models, with the best LSTM model achieving an AUROC of 0.78 versus 0.66 for the 14-variable LR and 0.71 for the 517-variable LR 2 hours after initiation. All models except for the 14-variable LR achieved higher AUROCs in the respiratory cohort than in the general intensive care unit population. Conclusions ML models trained using electronic medical record data were able to identify children at risk of HFNC failure within 24 hours of initiation. LSTM models that incorporated transfer learning, input data perseveration, and ensembling showed improved performance compared with the LR and standard LSTM models.
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Affiliation(s)
- George Pappy
- The Laura P. and Leland K. Whittier Virtual PICU, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Melissa Aczon
- The Laura P. and Leland K. Whittier Virtual PICU, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Randall Wetzel
- The Laura P. and Leland K. Whittier Virtual PICU, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - David Ledbetter
- The Laura P. and Leland K. Whittier Virtual PICU, Children's Hospital Los Angeles, Los Angeles, CA, United States
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Use of Negative Pressure Ventilation in Pediatric Critical Care: Experience in 56 PICUs in the Virtual Pediatric Systems Database (2009-2019). Pediatr Crit Care Med 2021; 22:e363-e368. [PMID: 33729731 DOI: 10.1097/pcc.0000000000002690] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Negative pressure ventilation may be more physiologic than positive pressure ventilation, but data describing negative pressure ventilation use in the PICU are limited. We aimed to describe the epidemiology and outcomes of PICU patients receiving negative pressure ventilation. DESIGN Descriptive analysis of a large, quality-controlled multicenter database. SETTING Fifty-six PICUs in the Virtual Pediatric Systems database who reported use of negative pressure ventilation. PATIENTS Children admitted to a participating PICU between 2009 and 2019 who received negative pressure ventilation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among 788 subjects, 71% were less than 2 years old, and 45% had underlying health conditions. Two concurrent aspiration events were the only adverse events reported. After excluding one over-represented center, the 3 years with the most negative pressure ventilation usage were 2017-2019 (all > 25 cases/yr and ≥ 13 centers reporting usage). Among those 187 children, the most common primary diagnoses were bronchiolitis and cardiac disease (both 15.5%), 24.1% required endotracheal intubation after negative pressure ventilation, and 9.1% died. CONCLUSIONS Negative pressure ventilation is being used in many PICUs, most commonly for pulmonary infections or cardiac disease, in children with high rates of subsequent intubation and mortality and with few documented adverse events. Use at individual centers is rare but increasing, suggesting need for prospective collaboration to better evaluate the role of negative pressure ventilation in the PICU.
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Impact of Failure of Noninvasive Ventilation on the Safety of Pediatric Tracheal Intubation. Crit Care Med 2021; 48:1503-1512. [PMID: 32701551 DOI: 10.1097/ccm.0000000000004500] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Noninvasive ventilation is widely used to avoid tracheal intubation in critically ill children. The objective of this study was to assess whether noninvasive ventilation failure was associated with severe tracheal intubation-associated events and severe oxygen desaturation during tracheal intubation. DESIGN Prospective multicenter cohort study of consecutive intubated patients using the National Emergency Airway Registry for Children registry. SETTING Thirteen PICUs (in 12 institutions) in the United States and Canada. PATIENTS All patients undergoing tracheal intubation in participating sites were included. Noninvasive ventilation failure group included children with any use of high-flow nasal cannula, continuous positive airway pressure, or bilevel noninvasive ventilation in the 6 hours prior to tracheal intubation. Primary tracheal intubation group included children without exposure to noninvasive ventilation within 6 hours before tracheal intubation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Severe tracheal intubation-associated events (cardiac arrest, esophageal intubation with delayed recognition, emesis with aspiration, hypotension requiring intervention, laryngospasm, pneumothorax, pneumomediastinum) and severe oxygen desaturation (< 70%) were recorded prospectively. The study included 956 tracheal intubation encounters; 424 tracheal intubations (44%) occurred after noninvasive ventilation failure, with a median of 13 hours (interquartile range, 4-38 hr) of noninvasive ventilation. Noninvasive ventilation failure group included more infants (47% vs 33%; p < 0.001) and patients with a respiratory diagnosis (56% vs 30%; p < 0.001). Noninvasive ventilation failure was not associated with severe tracheal intubation-associated events (5% vs 5% without noninvasive ventilation; p = 0.96) but was associated with severe desaturation (15% vs 9% without noninvasive ventilation; p = 0.005). After controlling for baseline differences, noninvasive ventilation failure was not independently associated with severe tracheal intubation-associated events (p = 0.35) or severe desaturation (p = 0.08). In the noninvasive ventilation failure group, higher FIO2 before tracheal intubation (≥ 70%) was associated with severe tracheal intubation-associated events. CONCLUSIONS Critically ill children are frequently exposed to noninvasive ventilation before intubation. Noninvasive ventilation failure was not independently associated with severe tracheal intubation-associated events or severe oxygen desaturation compared to primary tracheal intubation.
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Prevalence of Reintubation Within 24 Hours of Extubation in Bronchiolitis: Retrospective Cohort Study Using the Virtual Pediatric Systems Database. Pediatr Crit Care Med 2021; 22:474-482. [PMID: 33031349 DOI: 10.1097/pcc.0000000000002581] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES High-flow nasal cannula and noninvasive positive pressure ventilation are used to support children following liberation from invasive mechanical ventilation. Evidence comparing extubation failure rates between patients randomized to high-flow nasal cannula and noninvasive positive pressure ventilation is available for adult and neonatal patients; however, similar pediatric trials are lacking. In this study, we employed a quality controlled, multicenter PICU database to test the hypothesis that high-flow nasal cannula is associated with higher prevalence of reintubation within 24 hours among patients with bronchiolitis. DESIGN Secondary analysis of a prior study utilizing the Virtual Pediatric Systems database. SETTING One-hundred twenty-four participating PICUs. PATIENTS Children less than 24 months old with a primary diagnosis of bronchiolitis who were admitted to one of 124 PICUs between January 2009 and September 2015 and received invasive mechanical ventilation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among 759 patients, median age was 2.4 months (1.3-5.4 mo), 41.2% were female, 39.7% had greater than or equal to 1 comorbid condition, and 43.7% were Caucasian. Median PICU length of stay was 8.7 days (interquartile range, 5.8-13.7 d) and survival to PICU discharge was 100%. Median duration of intubation was 5.5 days (3.4-9.0 d) prior to initial extubation. High-flow nasal cannula was used following extubation in most (656 [86.5%]) analyzed subjects. The overall prevalence of reintubation within 24 hours was 5.9% (45 children). Extubation to noninvasive positive pressure ventilation was associated with greater prevalence of reintubation than extubation to high-flow nasal cannula (11.7% vs 5.0%; p = 0.016) and, in an a posteriori model that included Pediatric Index of Mortality 2 score and comorbidities, was associated with increased odds of reintubation (odds ratio, 2.43; 1.11-5.34; p = 0.027). CONCLUSIONS In this secondary analysis of a multicenter database of children with bronchiolitis, extubation to high-flow nasal cannula was associated with a lower prevalence of reintubation within 24 hours compared with noninvasive positive pressure ventilation in both unmatched and propensity-matched analysis. Prospective trials are needed to determine if post-extubation support modality can mitigate the risk of extubation failure.
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Wiser RK, Smith AC, Khallouq BB, Chen JG. A pediatric high-flow nasal cannula protocol standardizes initial flow and expedites weaning. Pediatr Pulmonol 2021; 56:1189-1197. [PMID: 33295690 DOI: 10.1002/ppul.25214] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/30/2020] [Accepted: 12/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Respiratory illnesses compose the most common diagnoses of patients admitted to pediatric intensive care units. In pediatrics, high-flow nasal cannula (HFNC) therapy is an intermediate level of respiratory support with variability in practice. We conducted a pre-post intervention study of patients placed on HFNC therapy before and after the implementation of an HFNC protocol. METHODS This was a quality improvement/pre-post intervention study of pediatric patients who received HFNC therapy in our teaching, tertiary care children's hospital between January 2015 and April 2019. Patients were evaluated before and after the implementation of a protocol that promoted initiation of higher flow and rapid weaning. Our primary outcomes were initial flow and rate of weaning pre- and post-protocol; our secondary outcomes were HFNC failure rate (defined as escalation to noninvasive ventilation or mechanical ventilation) and length of hospital stay. Propensity matching was used to account for differences in age and weight pre- and post-protocol. RESULTS In total, 584 patients were included, 292 pre-protocol, and 292 post-protocol. The median age was 20 months, and the indication for HFNC therapy was bronchiolitis in 29% of patients. Post-protocol patients compared to pre-protocol patients had significantly a higher initial flow (median 14.5 L/min vs. 10 L/min, p < .001) and a higher weaning rate of flow (median 4.1 L/min/h vs. 2.4 L/min/h, p < .001). Post-protocol patients also had a lower HFNC failure rate (10% vs. 17%, p = .015) and a shorter length of stay (5.97 days vs. 6.80 days, p = .006). CONCLUSION Among pediatric patients, the implementation of an HFNC protocol increases initial flow, allows for more rapid weaning, and may decrease the incidence of escalation to noninvasive ventilation or mechanical ventilation.
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Affiliation(s)
- Robert K Wiser
- Department of Pediatrics, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Ashlee C Smith
- Department of Pediatrics, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Bertha B Khallouq
- Department of Pediatrics, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Jerome G Chen
- Department of Pediatrics, Arnold Palmer Hospital for Children, Orlando, Florida, USA
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Christophe M, Julien B, Gilles C. Improving synchrony in young infants supported by noninvasive ventilation for severe bronchiolitis: Yes, we can… so we should! Pediatr Pulmonol 2021; 56:319-322. [PMID: 33270991 DOI: 10.1002/ppul.25184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/01/2020] [Accepted: 11/15/2020] [Indexed: 11/07/2022]
Affiliation(s)
- Milési Christophe
- Department of Neonatal Medicine and Pediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| | - Baleine Julien
- Department of Neonatal Medicine and Pediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| | - Cambonie Gilles
- Department of Neonatal Medicine and Pediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
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Update on the Role of High-Flow Nasal Cannula in Infants with Bronchiolitis. CHILDREN-BASEL 2021; 8:children8020066. [PMID: 33498527 PMCID: PMC7909574 DOI: 10.3390/children8020066] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/13/2021] [Accepted: 01/15/2021] [Indexed: 11/17/2022]
Abstract
Bronchiolitis (BR), a lower respiratory tract infection mainly caused by respiratory syncytial virus (RSV), can be very severe. Presently, adequate nutritional support and oxygen therapy remain the only interventions recommended to treat patients with BR. For years, mild BR cases were treated with noninvasive standard oxygen therapy (SOT), i.e., with cold and poorly or totally non-humidified oxygen delivered by an ambient headbox or low-flow nasal cannula. Children with severe disease were intubated and treated with invasive mechanical ventilation (IMV). To improve SOT and overcome the disadvantages of IMV, new measures of noninvasive and more efficient oxygen administration have been studied. Bi-level positive air way pressure (BiPAP), continuous positive airway pressure (CPAP), and high-flow nasal cannula (HFNC) are among them. For its simplicity, good tolerability and safety, and the good results reported in clinical studies, HFNC has become increasingly popular and is now widely used. However, consistent guidelines for initiation and discontinuation of HFNC are lacking. In this narrative review, the role of HFNC to treat infants with BR is discussed. An analysis of the literature showed that, despite its widespread use, the role of HFNC in preventing respiratory failure in children with BR is not precisely defined. It is not established whether it can offer greater benefits compared to SOT and when and in which infants it can replace CPAP or BiPAP. The analysis of the results clearly indicates the need for multicenter studies and official guidelines. In the meantime, HFNC can be considered a safe and effective method to treat children with mild to moderate BR who do not respond to SOT.
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Maamari M, Nino G, Bost J, Cheng Y, Sochet A, Sharron M. Predicting Failure of Non-Invasive Ventilation With RAM Cannula in Bronchiolitis. J Intensive Care Med 2021; 37:120-127. [PMID: 33412988 DOI: 10.1177/0885066620979642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION In infants hospitalized for bronchiolitis on non-invasive ventilation (NIV) via the RAM cannula nasal interface, variables predicting subsequent intubation, or NIV non-response, are understudied. We sought to identify predictors of NIV non-response. METHODS We performed a retrospective cohort study in infants admitted for respiratory failure from bronchiolitis placed on NIV in a quaternary children's hospital. We excluded children with concurrent sepsis, critical congenital heart disease, or with preexisting tracheostomy. The primary outcome was NIV non-response defined as intubation after a trial of NIV. Secondary outcomes were vital sign values before and after NIV initiation, duration of NIV and intubation, and mortality. Primary analyses included Chi-square, Wilcoxon rank-sum, student's t test, paired analyses, and adjusted and unadjusted logistic regression assessing heart rate (HR) and respiratory rate (RR) before and after NIV initiation. RESULTS Of 138 infants studied, 34% were non-responders. There were no differences in baseline characteristics of responders and non-responders. HR decreased after NIV initiation in responders (156 [143-156] to149 [141-158], p < 0.01) compared to non-responders (158 [149-166] to 158 [145-171], p = 0.73). RR decreased in responders (50 [43-58] vs 47 [41-54]) and non-responders (52 [48-58] vs 51 [40-55], both p < 0.01). Concurrent bacterial pneumonia (OR 6.06, 95% CI: 2.54-14.51) and persistently elevated HR (OR: 1.04, 95% CI: 1.01-1.07) were associated with NIV non-response. CONCLUSION In children with acute bronchiolitis who fail to respond to NIV and require subsequent intubation, we noted associations with persistently elevated HR after NIV initiation and concurrent bacterial pneumonia.
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Affiliation(s)
- Mia Maamari
- Division of Critical Care Medicine, 12334Children's National Health System, Washington, DC, USA
| | - Gustavo Nino
- Division of Pulmonology, 12334Children's National Health System, Washington, DC, USA
| | - James Bost
- Division of Biostatistics and Study Methodology, 12334Children's National Health System, Washington, DC, USA
| | - Yao Cheng
- Division of Biostatistics and Study Methodology, 12334Children's National Health System, Washington, DC, USA
| | - Anthony Sochet
- Division of Anesthesia and Critical Care Medicine, 1500Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Matthew Sharron
- Division of Critical Care Medicine, 12334Children's National Health System, Washington, DC, USA
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An Automated Scoring of Clinical Asthma Score: Proof of Concept and the Future Possibility. Crit Care Explor 2021; 3:e0319. [PMID: 33458686 PMCID: PMC7803746 DOI: 10.1097/cce.0000000000000319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Cassibba J, Mortamet G. Characteristics and Management of Severe Bronchiolitis Occurring in Ski Resorts in the French Alps: A Case Series. Pediatr Emerg Care 2021; 37:e68. [PMID: 32868624 DOI: 10.1097/pec.0000000000002220] [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: 11/26/2022]
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Sochet AA, Nunez M, Maamari M, McKinley S, Morrison JM, Nakagawa TA. Physiometric Response to High-Flow Nasal Cannula Support in Acute Bronchiolitis. Hosp Pediatr 2020; 11:94-99. [PMID: 33372047 DOI: 10.1542/hpeds.2020-001602] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To describe the rate of high-flow nasal cannula (HFNC) nonresponse and paired physiometric responses (changes [∆] in heart rate [HR] and respiratory rate [RR]) before and after HFNC initiation in hospitalized children with bronchiolitis. METHODS We performed a single-center, prospective descriptive study in a PICU within a quaternary referral center, assessing children aged ≤2 years admitted for bronchiolitis on HFNC from November 2017 to March 2020. We excluded for cystic fibrosis, airway anomalies, pulmonary hypertension, tracheostomy, neuromuscular disease, congenital heart disease, or preadmission intubation. Primary outcomes were paired ∆ and %∆ in HR and RR before and after HFNC initiation. Secondary outcomes were HFNC nonresponse rate (ie, intubation or transition to noninvasive positive pressure ventilation). Analyses included χ2, Student's t, Wilcoxon rank, and paired testing. RESULTS Of the 172 children studied, 56 (32.6%) experienced HFNC nonresponse at a median of 14.4 (interquartile range: 4.8-36) hours and 11 (6.4%) were intubated. Nonresponders had a greater frequency of bacterial pneumonia, but otherwise no major differences in demographics, comorbidities, or viral pathogens were noted. Responders experienced reductions in both %ΔRR (-17.1% ± 15.8% vs +5.3% ± 22.3%) and %ΔHR (-6.5% ± 10.5% vs 0% ± 10.9%) compared with nonresponders. CONCLUSIONS In this prospective, observational cohort study, we provide baseline data describing expected physiologic changes after initiation of HFNC for children admitted to the PICU for bronchiolitis. In our descriptive analysis, patients with comorbid bacterial pneumonia appear to be at additional risk for subsequent HFNC nonresponse.
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Affiliation(s)
- Anthony A Sochet
- Divisions of Pediatric Critical Care Medicine, .,Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland; and
| | | | - Mia Maamari
- Division of Pediatric Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - John M Morrison
- Pediatric Hospital Medicine, Johns Hopkins All Children's Hospital, St Petersburg, Florida.,Division of Hospital Medicine and
| | - Thomas A Nakagawa
- Divisions of Pediatric Critical Care Medicine.,Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland; and
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Has the introduction of high-flow nasal cannula modified the clinical characteristics and outcomes of infants with bronchiolitis admitted to pediatric intensive care units? A retrospective study. Arch Pediatr 2020; 28:141-146. [PMID: 33334653 DOI: 10.1016/j.arcped.2020.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 09/14/2020] [Accepted: 11/21/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND This study aimed to assess how the emergence of high-flow nasal cannula (HFNC) has modified the demographic and clinical characteristics as well as outcomes of infants with bronchiolitis admitted to a pediatric intensive care unit (PICU). METHODS This was a single-center retrospective study including infants aged 1 day to 6 months with bronchiolitis requiring HFNC, noninvasive ventilation (NIV), or invasive ventilation on admission. RESULTS A total of 252 infants (mean age 53±36 days) were included in the study. The use of HFNC increased from 18 (21.4%) during 2013-2014 to 53 infants (55.2%) during 2015-2016. The length of stay in the PICU decreased over time from 4.7±2.9 to 3.5±2.7 days (P<0.01) but the hospital length of stay remained similar (P=0.17). On admission, patients supported by HFNC as the first-line therapy were older. The PICU length of stay was similar according to the type of respiratory support (P=0.16), but the hospital length of stay was longer for patients supported by HFNC (P=0.01). CONCLUSION The distribution of respiratory support has significantly changed over time for patients with bronchiolitis and HFNC is increasingly used. The demographic and clinical characteristics of the have not changed over time. However, the PICU length of stay decreased significantly.
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Angurana SK, Williams V, Takia L. Acute Viral Bronchiolitis: A Narrative Review. J Pediatr Intensive Care 2020; 12:79-86. [PMID: 37082471 PMCID: PMC10113010 DOI: 10.1055/s-0040-1715852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 07/09/2020] [Indexed: 10/23/2022] Open
Abstract
AbstractAcute viral bronchiolitis (AVB) is the leading cause of hospital admissions among infants in developed and developing countries and associated with increased morbidity and cost of treatment. This review was performed to guide the clinicians managing AVB in light of evidence accumulated in the last decade. We searched published English literature in last decade regarding etiology, diagnosis, treatment, and prevention of AVB using PubMed and Cochrane Database of Systematic Reviews. Respiratory syncytial virus is the most common causative agent. The diagnosis is mainly clinical with limited role of diagnostic investigations and chest radiographs are not routinely indicated. The management of AVB remains a challenge, as the role of various interventions is not clear. Supportive care in from of provision of heated and humidified oxygen and maintaining hydration are main interventions. The use of pulse oximetry helps to guide the administration of oxygen. Trials and systematic reviews evaluated various interventions like nebulized adrenaline, bronchodilators and hypertonic saline, corticosteroids, different modes of noninvasive ventilation (high-flow nasal cannula [HFNC], continuous positive airway pressure [CPAP], and noninvasive positive pressure ventilation [NPPV]), surfactant, heliox, chest physiotherapy, and antiviral drugs. The interventions which showed some benefits in infants and children with AVB are adrenaline and hypertonic saline nebulization, HFNC, CPAP, NIV, and surfactant. The routine administration of antibiotics, bronchodilators, corticosteroids, steam inhalation, chest physiotherapy, heliox, and antiviral drugs are not recommended.
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Affiliation(s)
- Suresh K. Angurana
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vijai Williams
- Pediatric Intensive Care Unit, Gleneagles Global Hospitals, Perumbakkam, Chennai, India
| | - Lalit Takia
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Carter MR, Khan AH, Salman T, Speicher R, Rotta AT, Shein SL. Emergency room endotracheal intubation in children with bronchiolitis: A cohort study using a multicenter database. Health Sci Rep 2020; 3:e169. [PMID: 32617417 PMCID: PMC7325424 DOI: 10.1002/hsr2.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND AND AIMS Bronchiolitis and asthma have a clinical overlap, and it has been shown that pediatric intensive care unit (PICU) patients with asthma undergoing endotracheal intubation in a community hospital emergency room (ER) have a shorter duration of mechanical ventilation (MV) and PICU length of stay (LOS) vs children undergoing intubation in a children's hospital. We aimed to determine if the setting of intubation (community vs children's hospital ER) is associated with the duration of MV and PICU LOS among children with bronchiolitis. METHODS With IRB approval, data in the Virtual Pediatric Systems (VPS, LLC) database were queried for bronchiolitis patients <24 months of age admitted to one of 103 predominantly North American PICUs between 1/2009 and 1/2016 who had an endotracheal tube in place at PICU admission. There were no exclusion criteria. Extracted data included ER type (community/external or children's hospital/internal), demographics, and reported comorbidities. Outcomes analyzed were duration of MV and PICU LOS. Multivariable linear regression was used to evaluate if intubation location was independently associated with the outcomes of interest. RESULTS Among 1934 patients, median age was 2.0 (IQR: 1.0-4.8) months, 51% were admitted from an external ER, 41% were White, 61% were male, and 28% had ≥1 comorbidity. Median duration of MV was 6.6 (4.6-9.5) days and the median PICU LOS was 7.0 (4.6-10.6) days. Children who underwent endotracheal intubation in a children's hospital ER had a modestly longer duration of MV (6.7 [4.4-9.4] vs 6.5 [5.2-9.6] days, P < .001, Mann-Whitney U) and longer PICU LOS (7.2 [4.8-10.8] vs 6.9 [4.2-10.1] days, P = .004, Mann-Whitney U). After adjusting for confounding variables, we did not observe a significant association between the location of endotracheal intubation and duration of MV or PICU LOS. CONCLUSION In this cohort, and unlike outcomes of near-fatal asthma, we observed that clinical outcomes of critical bronchiolitis were similar regardless of location of endotracheal intubation.
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Affiliation(s)
- Marla R. Carter
- Division of Pediatric Critical Care Medicine, Department of PediatricsRainbow Babies and Children's HospitalClevelandOhio
| | - Aamer H. Khan
- Division of Pediatric Critical Care Medicine, Department of PediatricsRainbow Babies and Children's HospitalClevelandOhio
| | - Tarek Salman
- Division of Pediatric Critical Care Medicine, Department of PediatricsRainbow Babies and Children's HospitalClevelandOhio
| | - Richard Speicher
- Division of Pediatric Critical Care Medicine, Department of PediatricsRainbow Babies and Children's HospitalClevelandOhio
| | - Alexandre T. Rotta
- Division of Pediatric Critical Care Medicine, Department of PediatricsRainbow Babies and Children's HospitalClevelandOhio
| | - Steven L. Shein
- Division of Pediatric Critical Care Medicine, Department of PediatricsRainbow Babies and Children's HospitalClevelandOhio
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Mammas IN, Drysdale SB, Rath B, Theodoridou M, Papaioannou G, Papatheodoropoulou A, Koutsounaki E, Koutsaftiki C, Kozanidou E, Achtsidis V, Korovessi P, Chrousos GP, Spandidos DA. Update on current views and advances on RSV infection (Review). Int J Mol Med 2020; 46:509-520. [PMID: 32626981 PMCID: PMC7307844 DOI: 10.3892/ijmm.2020.4641] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 06/15/2020] [Indexed: 12/11/2022] Open
Abstract
Respiratory syncytial virus (RSV) infection represents an excellent paradigm of precision medicine in modern paediatrics and several clinical trials are currently performed in the prevention and management of RSV infection. A new taxonomic terminology for RSV was recently adopted, while the diagnostic and omics techniques have revealed new modalities in the early identification of RSV infections and for better understanding of the disease pathogenesis. Coordinated clinical and research efforts constitute an important step in limiting RSV global predominance, improving epidemiological surveillance, and advancing neonatal and paediatric care. This review article presents the key messages of the plenary lectures, oral presentations and posters of the '5th workshop on paediatric virology' (Sparta, Greece, 12th October 2019) organized by the Paediatric Virology Study Group, focusing on recent advances in the epidemiology, pathogenesis, diagnosis, prognosis, clinical management and prevention of RSV infection in childhood.
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Affiliation(s)
- Ioannis N Mammas
- Laboratory of Clinical Virology, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | | | - Barbara Rath
- Vienna Vaccine Safety Initiative, D‑10437 Berlin, Germany
| | - Maria Theodoridou
- First Department of Paediatrics, University of Athens School of Medicine, 11527 Athens, Greece
| | - Georgia Papaioannou
- Department of Paediatric Radiology, 'Mitera' Children's Hospital, 15123 Athens, Greece
| | | | - Eirini Koutsounaki
- Neonatal Department, 'Alexandra' Maternity Hospital, 15123 Athens, Greece
| | - Chryssie Koutsaftiki
- Paediatric Intensive Care Unit (PICU), 'Penteli' Children's Hospital, 15236 Penteli, Greece
| | - Eleftheria Kozanidou
- 2nd Department of Internal Medicine, 'St Panteleimon' General Hospital of Nikaia, 18454 Piraeus, Greece
| | - Vassilis Achtsidis
- Department of Ophthalmology, Royal Cornwall Hospitals, Cornwall TR1 3LQ, UK
| | - Paraskevi Korovessi
- Department of Paediatrics, 'Penteli' Children's Hospital, 15236 Penteli, Greece
| | - George P Chrousos
- First Department of Paediatrics, University of Athens School of Medicine, 11527 Athens, Greece
| | - Demetrios A Spandidos
- Laboratory of Clinical Virology, School of Medicine, University of Crete, 71003 Heraklion, Greece
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Cesar RG, Bispo BRP, Felix PHCA, Modolo MCC, Souza AAF, Horigoshi NK, Rotta AT. High-Flow Nasal Cannula versus Continuous Positive Airway Pressure in Critical Bronchiolitis: A Randomized Controlled Pilot. J Pediatr Intensive Care 2020; 9:248-255. [PMID: 33133739 DOI: 10.1055/s-0040-1709656] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 03/10/2020] [Indexed: 12/17/2022] Open
Abstract
We conducted a randomized controlled pilot study in infants with critical bronchiolitis ( n = 63) comparing high-flow nasal cannula (HFNC, n = 35) to continuous positive airway pressure (CPAP, n = 28). The primary outcome was treatment failure, defined as the need for bilevel positive pressure ventilation or endotracheal intubation. Treatment failure occurred in 10 patients (35.7%) in the CPAP group and 13 patients (37.1%) in the HFNC group ( p = 0.88). Pediatric intensive care unit length of stay was similar between the CPAP and HFNC groups (5 [4-7] days and 5 [4-8] days, p = 0.46, respectively). In this pilot study, treatment with HFNC resulted in a rate of treatment failure similar to CPAP.
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Affiliation(s)
- Regina Grigolli Cesar
- Unidade de Terapia Intensiva, Hospital Infantil Sabará e Instituto PENSI, São Paulo, Brazil
| | | | | | | | | | - Nelson K Horigoshi
- Unidade de Terapia Intensiva, Hospital Infantil Sabará e Instituto PENSI, São Paulo, Brazil
| | - Alexandre T Rotta
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina, United States
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Korppi M. Prospective real-life studies are needed on bronchiolitis treatment protocols. Pediatr Pulmonol 2020; 55:853-854. [PMID: 32032462 DOI: 10.1002/ppul.24682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 01/25/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Matti Korppi
- Faculty of Medicine and Life Sciences, Center for Child Health Research, University of Tampere and University Hospital, Tampere, Finland
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Habra B, Janahi IA, Dauleh H, Chandra P, Veten A. A comparison between high-flow nasal cannula and noninvasive ventilation in the management of infants and young children with acute bronchiolitis in the PICU. Pediatr Pulmonol 2020; 55:455-461. [PMID: 31922360 DOI: 10.1002/ppul.24553] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 10/12/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Different modalities of noninvasive respiratory support have been recommended for the management of acute bronchiolitis in the pediatric intensive care unit (PICU). High-flow nasal cannula (HFNC) is among the new modalities that have been widely used in the last decade. METHODS This is a retrospective study involving infants and young children between the ages of 1 month and 2 years during the respiratory season of 2016-2017 (October-May). We compared the failure rate of HFNC with the failure rates of bi-level positive airway pressure (BiPAP) vs continuous positive airway pressure (CPAP) in the management of acute bronchiolitis in the PICU. Failure was defined as a change to another respiratory support modality or endotracheal intubation and mechanical ventilation. RESULTS One hundred thirty-seven patients met the inclusion criteria, of which 77 patients needed HFNC, 10 needed CPAP, and 50 were on BiPAP. Among baseline characteristics, there were significant variations in age among the three groups. HFNC had a higher failure rate compared with the other two noninvasive ventilation modalities (50.6% for HFNC [n = 39 out of 77] vs 0% for CPAP [n = 0 out of 10] vs 8% for BiPAP [n = 4 out of 50], P < .01). Among the 39 patients who failed HFNC, 90% were successfully shifted to BiPAP and weaned off later, whereas the other 4 were intubated and required mechanical ventilation. However, all four patients who failed BiPAP were intubated and mechanically ventilated. No respiratory complications or mortalities were reported in the three groups. No differences were observed among the three groups in terms of the lengths of PICU or hospital stays. CONCLUSIONS We observed a higher failure rate of HFNC compared with BiPAP or CPAP in the management of infants and children with acute bronchiolitis in the PICU. Further prospective randomized trials are recommended to confirm this finding.
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Affiliation(s)
- Basel Habra
- Department of Pediatric Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Ibrahim A Janahi
- Department of Pediatric Medicine, Hamad Medical Corporation, Doha, Qatar.,Department of Pediatric Medicine, Sidra Medicine, Doha, Qatar.,Weill Cornell Medicine, Doha, Qatar
| | - Hajer Dauleh
- Department of Pediatric Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Prem Chandra
- Department of Pediatric Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Veten
- Department of Pediatric Medicine, Hamad Medical Corporation, Doha, Qatar
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The authors reply. Pediatr Crit Care Med 2019; 20:1211-1212. [PMID: 31804449 DOI: 10.1097/pcc.0000000000002141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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The author replies. Pediatr Crit Care Med 2019; 20:793-794. [PMID: 31397819 DOI: 10.1097/pcc.0000000000002025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The author replies. Pediatr Crit Care Med 2019; 20:798. [PMID: 31397824 DOI: 10.1097/pcc.0000000000002026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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High Flow, High Flow: It's Off to Work We Go. Pediatr Crit Care Med 2019; 20:292-293. [PMID: 30830018 DOI: 10.1097/pcc.0000000000001819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Noninvasive High Flow Versus Noninvasive Positive Pressure in Children With Severe Bronchiolitis: The Battle of the PICU Continues. Pediatr Crit Care Med 2019; 20:192-193. [PMID: 30720651 DOI: 10.1097/pcc.0000000000001800] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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