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Cave C, Samano D, Sharma AM, Dickinson J, Salomon J, Mahapatra S. Acute respiratory distress syndrome: A review of ARDS across the life course. J Investig Med 2024:10815589241270612. [PMID: 39092841 DOI: 10.1177/10815589241270612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
Acute respiratory distress syndrome (ARDS) is a multifactorial, inflammatory lung disease with significant morbidity and mortality that predominantly requires supportive care in its management. Although initially described in adult patients, the diagnostic definitions for ARDS have evolved over time to accurately describe this disease process in pediatric and, more recently, neonatal patients. The management of ARDS in each age demographic has converged in the application of lung-protective ventilatory strategies to mitigate the primary disease process and prevent its exacerbation by limiting ventilator-induced lung injury. However, differences arise in the preferred ventilatory strategies or adjunctive pulmonary therapies used to mitigate each type of ARDS. In this review, we compare and contrast the epidemiology, common etiologies, pathophysiology, diagnostic criteria, and outcomes of ARDS across the lifespan. Additionally, we discuss in detail the different management strategies used for each subtype of ARDS and spotlight how these strategies were applied to mitigate poor outcomes during the COVID-19 pandemic. This review is geared toward both clinicians and clinician-scientists as it not only summarizes the latest information on disease pathogenesis and patient management in ARDS across the lifespan but also highlights knowledge gaps for further investigative efforts. We conclude by projecting how future studies can fill these gaps in research and what improvements may be envisioned in the management of NARDS and PARDS based on the current breadth of literature on adult ARDS treatment strategies.
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Affiliation(s)
- Caleb Cave
- Division of Neonatology, and Division of Pulmonology, Department of Pediatrics, Children's Hospital and Medical Center, Omaha, University of Nebraska Medical Center, Omaha, NE, USA
| | - Dannielle Samano
- Division of Pulmonary, Sleep, and Critical Care Medicine, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Abhineet M Sharma
- Division of Neonatology, and Division of Pulmonology, Department of Pediatrics, Children's Hospital and Medical Center, Omaha, University of Nebraska Medical Center, Omaha, NE, USA
| | - John Dickinson
- Division of Pulmonary, Sleep, and Critical Care Medicine, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Jeffrey Salomon
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital and Medical Center, Omaha, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sidharth Mahapatra
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital and Medical Center, Omaha, University of Nebraska Medical Center, Omaha, NE, USA
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Wu W, He Y, Lin D, Zhang G, Zhang X, Zhang N, Xie T, Wei H. Dexmedetomidine mitigates lipopolysaccharide-induced acute lung injury by modulating heat shock protein A12B to inhibit the toll-like receptor 4/nuclear factor-kappa B signaling pathway. Chem Biol Interact 2024; 398:111112. [PMID: 38901789 DOI: 10.1016/j.cbi.2024.111112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 06/03/2024] [Accepted: 06/17/2024] [Indexed: 06/22/2024]
Abstract
Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS): Life-threatening medical conditions characterized by high morbidity and mortality rates, where the inflammatory process plays a crucial role in lung tissue damage, especially in models induced by lipopolysaccharide (LPS). Heat shock protein A12B (HSPA12B) has strong anti-infammatory properties However, it is unknown whether increased HSPA12B is protective against LPS-induced ALI. And Dexmedetomidine (DEX) is a potent α2-adrenergic receptor (α2-AR) agonist that has been shown to protect against sepsis-induced lung injury, however, the underlying mechanisms of this protection are not fully understood. This study utilized bioinformatics analysis and an LPS-induced ALI model to explore how DEX alleviates lung injury by modulating HSPA12B and inhibiting the Toll-like receptor 4/nuclear factor-kappa B (TLR4/NF-κB) signaling pathway. Results indicate that HSPA12B overexpression and DEX pre-treatment markedly mitigated LPS-induced lung injury, which was evaluated by the deterioration of histopathology, histologic scores, the W/D weight ratio, and total protein expression, tumor necrosis factor-alpha (TNF-α), and interleukin-1β (IL-1β) in the BALF, and the levels of NO, MDA,SOD and MPO in the lung. Moreover, HSPA12B overexpression and DEX pre-treatment significantly reduces lung injury and inflammation levels by upregulating HSPA12B and inhibiting the activation of the TLR4/NF-κB signaling pathway. On the contrary, when the expression of HSPA12B is inhibited, the protective effect of DEX pre-treatment on lung tissue is significantly weakened.In summary, our research demonstrated that the increased expression of AAV-mediated HSPA12B in the lungs of mice inhibits acute inflammation and suppresses the activation of TLR4/NF-κB pathway in a murine model of LPS-induced ALI. DEX could enhance HSPA12B and inhibit the initiation and development of inflammation through down-regulating TLR4/NF-κB pathway.These findings highlight the potential of DEX as a therapeutic agent for treating ALI and ARDS, offering new strategies for clinical intervention.
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Affiliation(s)
- Weifang Wu
- The Department of Anesthesiology, Fuzhou First General Hospital Affiliated with Fujian Medical University, Fuzhou, 350001, Fujian, China; The Third Clinical Medical College of Fujian Medical University, Fuzhou, 350122, Fujian, China
| | - Yi He
- The Third Clinical Medical College of Fujian Medical University, Fuzhou, 350122, Fujian, China; The Department of Anesthesiology, Affiliated Nanping First Hospital, Fujian Medical University, Nanping, 353000, Fujian, China
| | - Duoduo Lin
- The School of Pharmacy, Fujian Medical University, Fuzhou, 350122, Fujian, China
| | - Guifei Zhang
- The School of Pharmacy, Fujian Medical University, Fuzhou, 350122, Fujian, China
| | - Xutao Zhang
- The Third Clinical Medical College of Fujian Medical University, Fuzhou, 350122, Fujian, China
| | - Nanwen Zhang
- The School of Pharmacy, Fujian Medical University, Fuzhou, 350122, Fujian, China; Fujian Key Laboratory of Natural Medicine Pharmacology, School of Pharmacy, Fujian Medical University, Fuzhou, 350122, Fujian, China.
| | - Tingliang Xie
- The School of Pharmacy, Fujian Medical University, Fuzhou, 350122, Fujian, China; The School of Medical, Minjiang Teachers College, Fuzhou, 350108, Fujian, China.
| | - Haixiang Wei
- The Third Clinical Medical College of Fujian Medical University, Fuzhou, 350122, Fujian, China; The Department of Anesthesiology, Affiliated Nanping First Hospital, Fujian Medical University, Nanping, 353000, Fujian, China.
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3
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Goodfellow LT, Miller AG, Varekojis SM, LaVita CJ, Glogowski JT, Hess DR. AARC Clinical Practice Guideline: Patient-Ventilator Assessment. Respir Care 2024; 69:1042-1054. [PMID: 39048148 PMCID: PMC11298231 DOI: 10.4187/respcare.12007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Given the important role of patient-ventilator assessments in ensuring the safety and efficacy of mechanical ventilation, a team of respiratory therapists and a librarian used Grading of Recommendations, Assessment, Development, and Evaluation methodology to make the following recommendations: (1) We recommend assessment of plateau pressure to ensure lung-protective ventilator settings (strong recommendation, high certainty); (2) We recommend an assessment of tidal volume (VT) to ensure lung-protective ventilation (4-8 mL/kg/predicted body weight) (strong recommendation, high certainty); (3) We recommend documenting VT as mL/kg predicted body weight (strong recommendation, high certainty); (4) We recommend an assessment of PEEP and auto-PEEP (strong recommendation, high certainty); (5) We suggest assessing driving pressure to prevent ventilator-induced injury (conditional recommendation, low certainty); (6) We suggest assessing FIO2 to ensure normoxemia (conditional recommendation, very low certainty); (7) We suggest telemonitoring to supplement direct bedside assessment in settings with limited resources (conditional recommendation, low certainty); (8) We suggest direct bedside assessment rather than telemonitoring when resources are adequate (conditional recommendation, low certainty); (9) We suggest assessing adequate humidification for patients receiving noninvasive ventilation (NIV) and invasive mechanical ventilation (conditional recommendation, very low certainty); (10) We suggest assessing the appropriateness of the humidification device during NIV and invasive mechanical ventilation (conditional recommendation, low certainty); (11) We recommend that the skin surrounding artificial airways and NIV interfaces be assessed (strong recommendation, high certainty); (12) We suggest assessing the dressing used for tracheostomy tubes and NIV interfaces (conditional recommendation, low certainty); (13) We recommend assessing the pressure inside the cuff of artificial airways using a manometer (strong recommendation, high certainty); (14) We recommend that continuous cuff pressure assessment should not be implemented to decrease the risk of ventilator-associated pneumonia (strong recommendation, high certainty); and (15) We suggest assessing the proper placement and securement of artificial airways (conditional recommendation, very low certainty).
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Affiliation(s)
- Lynda T Goodfellow
- Director of AARC Clinical Practice Guideline Development and is affiliated with American Association for Respiratory Care/Daedalus Enterprises, Irving, Texas, and Georgia State University, Atlanta, Georgia
| | | | | | | | | | - Dean R Hess
- Massachusetts General Hospital, Boston, Massachusetts; and Daedalus Enterprises, Irving, Texas
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Yang H, Gao LJ, Lei J, Li Q, Cui L, Li XH, Yin WX, Tian SH. Relationship between neonatal respiratory distress syndrome pulmonary ultrasonography and respiratory distress score, oxygenation index, and chest radiography grading. World J Clin Cases 2024; 12:4154-4165. [PMID: 39015913 PMCID: PMC11235558 DOI: 10.12998/wjcc.v12.i20.4154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 05/17/2024] [Accepted: 06/03/2024] [Indexed: 06/30/2024] Open
Abstract
BACKGROUND Accurate condition assessment is critical for improving the prognosis of neonatal respiratory distress syndrome (RDS), but current assessment methods for RDS pose a cumulative risk of harm to neonates. Thus, a less harmful method for assessing the health of neonates with RDS is needed. AIM To analyze the relationships between pulmonary ultrasonography and respiratory distress scores, oxygenation index, and chest X-ray grade of neonatal RDS to identify predictors of neonatal RDS severity. METHODS This retrospective study analyzed the medical information of 73 neonates with RDS admitted to the neonatal intensive care unit of Liupanshui Maternal and Child Care Service Center between April and December 2022. The pulmonary ultrasonography score, respiratory distress score, oxygenation index, and chest X-ray grade of each newborn before and after treatment were collected. Spearman correlation analysis was performed to determine the relationships among these values and neonatal RDS severity. RESULTS The pulmonary ultrasonography score, respiratory distress score, oxygenation index, and chest X-ray RDS grade of the neonates were significantly lower after treatment than before treatment (P < 0.05). Spearman correlation analysis showed that before and after treatment, the pulmonary ultrasonography score of neonates with RDS was positively correlated with the respiratory distress score, oxygenation index, and chest X-ray grade (ρ = 0.429-0.859, P < 0.05). Receiver operating characteristic curve analysis indicated that pulmonary ultrasonography screening effectively predicted the severity of neonatal RDS (area under the curve = 0.805-1.000, P < 0.05). CONCLUSION The pulmonary ultrasonography score was significantly associated with the neonatal RDS score, oxygenation index, and chest X-ray grade. The pulmonary ultrasonography score was an effective predictor of neonatal RDS severity.
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Affiliation(s)
- Hai Yang
- Neonatal Intensive Care Center, Liupanshui Maternal and Child Care Service Center, Liupanshui 553000, Guizhou Province, China
| | - Li-Jun Gao
- Ultrasound Function Department, Liupanshui Maternal and Child Care Service Center, Liupanshui 553000, Guizhou Province, China
| | - Jing Lei
- Neonatal Intensive Care Center, Liupanshui Maternal and Child Care Service Center, Liupanshui 553000, Guizhou Province, China
| | - Qiang Li
- Neonatal Intensive Care Center, Liupanshui Maternal and Child Care Service Center, Liupanshui 553000, Guizhou Province, China
| | - Liu Cui
- Neonatal Intensive Care Center, Liupanshui Maternal and Child Care Service Center, Liupanshui 553000, Guizhou Province, China
| | - Xiao-Hua Li
- Neonatal Intensive Care Center, Liupanshui Maternal and Child Care Service Center, Liupanshui 553000, Guizhou Province, China
| | - Wu-Xuan Yin
- Neonatal Intensive Care Center, Liupanshui Maternal and Child Care Service Center, Liupanshui 553000, Guizhou Province, China
| | - Sen-Hua Tian
- Medical Imaging Department, Liupanshui Maternal and Child Care Service Center, Liupanshui 553000, Guizhou Province, China
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Vedrenne-Cloquet M, Tuffet S, Louis B, Khirani S, Collignon C, Renolleau S, Fauroux B, Carteaux G. Accuracy of tidal volume delivery by paediatric intensive care ventilators: A bench-model study. Aust Crit Care 2024; 37:600-605. [PMID: 38267269 DOI: 10.1016/j.aucc.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 11/06/2023] [Accepted: 12/02/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Tidal volume (Vt) delivery during mechanical ventilation is influenced by gas compression, humidity, and temperature. OBJECTIVES This bench study aimed at assessing the accuracy of Vt delivery by paediatric intensive care ventilators according to the humidification system. Secondary objectives were to assess the following: (i) the accuracy of Vt delivery in ventilators with an integrated Y-piece pneumotachograph and (ii) the ability of ventilators to deliver and maintain a preset positive end-expiratory pressure. METHODS Six latest-generation intensive care ventilators equipped with a paediatric mode were tested on the ASL5000 test lung in four simulated paediatric bench models (full-term neonate, infant, preschool-age chile, and school-age child), under volume-controlled mode with a heated humidifier (HH) or a heat moisture exchanger, with various loading conditions. Three ventilators equipped with a Y-piece pneumotachograph were tested with or without the pneumotachograph in the neonatal and infant models. "Accurate Vt" delivery was defined as a volume error (percentage of the preset Vt under body temperature and pressure and saturated water vapour conditions) being ≤10 % of the absolute preset value. RESULTS Vt accuracy varied significantly across ventilators but was acceptable in almost all the ventilators and all the models, except the neonatal model. The humidification system had an impact on Vt delivery in the majority of the tested conditions (p < 0.05). The use of an HH was associated with a better Vt accuracy in four ventilators (V500, V800, R860, and ServoU) and allowed to achieve an acceptable level of volume error in the neonatal model as compared to the use of heat moisture exchanger. The use of an integrated pneumotachograph was associated with lower volume error in only one ventilator (p < 0.01). All the tested ventilators were able to maintain adequate positive end-expiratory pressure levels. CONCLUSION The humidification system affects Vt accuracy of paediatric intensive care ventilators, especially in the youngest patients for whom the HH should be preferred.
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Affiliation(s)
- Meryl Vedrenne-Cloquet
- Pediatric Sleep and Noninvasive Ventilation Unit, EA 7330 VIFASOM, AP-HP, Hôpital Necker Enfants-Malades, Paris, France; Université de Paris, Paris, France; Réanimation Médicochirurgicale Pédiatrique, AP-HP, CHU Necker-Enfants Malades, Paris, France.
| | - Samuel Tuffet
- INSERM, Université Paris Est Créteil IMRB, CNRS EMR, 7000, Créteil, France; GRC CARMAS, IMRB, Université Paris Est Créteil, Faculté de Santé de Créteil, Créteil, France; Réanimation Médicale, AP-HP, Centre Hospitalier Universitaire Henri Mondor, Créteil, France
| | - Bruno Louis
- INSERM, Université Paris Est Créteil IMRB, CNRS EMR, 7000, Créteil, France
| | - Sonia Khirani
- Pediatric Sleep and Noninvasive Ventilation Unit, EA 7330 VIFASOM, AP-HP, Hôpital Necker Enfants-Malades, Paris, France; Université de Paris, Paris, France; ASV Santé, Gennevilliers, France
| | - Charlotte Collignon
- Réanimation Médicochirurgicale Pédiatrique, AP-HP, CHU Necker-Enfants Malades, Paris, France
| | - Sylvain Renolleau
- Université de Paris, Paris, France; Réanimation Médicochirurgicale Pédiatrique, AP-HP, CHU Necker-Enfants Malades, Paris, France
| | - Brigitte Fauroux
- Pediatric Sleep and Noninvasive Ventilation Unit, EA 7330 VIFASOM, AP-HP, Hôpital Necker Enfants-Malades, Paris, France; Université de Paris, Paris, France
| | - Guillaume Carteaux
- INSERM, Université Paris Est Créteil IMRB, CNRS EMR, 7000, Créteil, France; GRC CARMAS, IMRB, Université Paris Est Créteil, Faculté de Santé de Créteil, Créteil, France; Réanimation Médicale, AP-HP, Centre Hospitalier Universitaire Henri Mondor, Créteil, France
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6
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Tasker RC, Kochanek PM. 25 Years of Pediatric Critical Care Medicine: An Evolving Journal. Pediatr Crit Care Med 2024; 25:583-587. [PMID: 38958547 DOI: 10.1097/pcc.0000000000003546] [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: 07/04/2024]
Affiliation(s)
- Robert C Tasker
- orcid.org/0000-0003-3647-8113
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Selwyn College, Cambridge University, United Kingdom
| | - Patrick M Kochanek
- Department of Critical Care Medicine, Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
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Karsies T, Shein SL, Diaz F, Vasquez-Hoyos P, Alexander R, Pon S, González-Dambrauskas S. Prevalence of Bacterial Codetection and Outcomes for Infants Intubated for Respiratory Infections. Pediatr Crit Care Med 2024; 25:609-620. [PMID: 38530103 DOI: 10.1097/pcc.0000000000003500] [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: 03/27/2024]
Abstract
OBJECTIVES To determine the prevalence of respiratory bacterial codetection in children younger than 2 years intubated for acute lower respiratory tract infection (LRTI), primarily viral bronchiolitis, and identify the association of codetection with mechanical ventilation duration. DESIGN Prospective observational study evaluating the prevalence of bacterial codetection (moderate/heavy growth of pathogenic bacterial plus moderate/many polymorphonuclear neutrophils) and the impact of codetection on invasive mechanical ventilation (IMV) duration. SETTING PICUs in 12 high and low/middle-income countries. PATIENTS Children younger than 2 years old requiring intubation and ICU admission for LRTI and who had a lower respiratory tract culture obtained at the time of intubation between December 1, 2019, and November 30, 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 472 analyzed patients (median age 4.5 mo), 55% had a positive respiratory culture and 29% ( n = 138) had codetection. 90% received early antibiotics starting at a median of 0.36 hours after respiratory culture. Median (interquartile range) IMV duration was 151 hours (88, 226), and there were 28 deaths (5.3%). Codetection was more common with younger age, a positive respiratory syncytial virus test, and an admission diagnosis of bronchiolitis; it was less common with an admission diagnosis of pneumonia, with admission to a low-/middle-income site, and in those receiving vasopressors. When adjusted for confounders, codetection was not associated with longer IMV duration (adjusted relative risk 0.854 [95% CI 0.684-1.065]). We could not exclude the possibility that codetection might be associated with a 30-hour shorter IMV duration compared with no codetection, although the CI includes the null value. CONCLUSIONS Bacterial codetection was present in almost a third of children younger than 2 years requiring intubation and ICU admission for LRTI, but this was not associated with prolonged IMV. Further large studies are needed to evaluate if codetection is associated with shorter IMV duration.
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Affiliation(s)
- Todd Karsies
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Steven L Shein
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Franco Diaz
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
- Departamento de Pediatriá, Unidad de Paciente Critico Pediátrico, Hospital El Carmen de Maipú, Santiago, Chile
- Unidad de Investigación y Epidemiología Clínica, Escuela de Medicina, Universidad Finis Terrae, Santiago, Chile
| | - Pablo Vasquez-Hoyos
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
- Departamento de Pediatriá, Sociedad de Cirugía de Bogotá Hospital de San José, FUCS, Bogotá, Colombia
| | - Robin Alexander
- Biostatistics Resource at Nationwide Children's Hospital (BRANCH), Columbus, OH
| | - Steven Pon
- Weill Cornell Medical College, New York, NY
| | - Sebastián González-Dambrauskas
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
- Departamento de Pediatría y Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
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Wong JJM, Dang H, Gan CS, Phan PH, Kurosawa H, Aoki K, Lee SW, Ong JSM, Fan L, Tai CW, Chuah SL, Lee PC, Chor YK, Ngu L, Anantasit N, Liu C, Xu W, Wati DK, Gede SIB, Jayashree M, Liauw F, Pon KM, Huang L, Chong JY, Zhu X, Hon KLE, Leung KKY, Samransamruajkit R, Cheung YB, Lee JH. Lung-Protective Ventilation for Pediatric Acute Respiratory Distress Syndrome: A Nonrandomized Controlled Trial. Crit Care Med 2024:00003246-990000000-00353. [PMID: 38920618 DOI: 10.1097/ccm.0000000000006357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
OBJECTIVES Despite the recommendation for lung-protective mechanical ventilation (LPMV) in pediatric acute respiratory distress syndrome (PARDS), there is a lack of robust supporting data and variable adherence in clinical practice. This study evaluates the impact of an LPMV protocol vs. standard care and adherence to LPMV elements on mortality. We hypothesized that LPMV strategies deployed as a pragmatic protocol reduces mortality in PARDS. DESIGN Multicenter prospective before-and-after comparison design study. SETTING Twenty-one PICUs. PATIENTS Patients fulfilled the Pediatric Acute Lung Injury Consensus Conference 2015 definition of PARDS and were on invasive mechanical ventilation. INTERVENTIONS The LPMV protocol included a limit on peak inspiratory pressure (PIP), delta/driving pressure (DP), tidal volume, positive end-expiratory pressure (PEEP) to Fio2 combinations of the low PEEP acute respiratory distress syndrome network table, permissive hypercarbia, and conservative oxygen targets. MEASUREMENTS AND MAIN RESULTS There were 285 of 693 (41·1%) and 408 of 693 (58·9%) patients treated with and without the LPMV protocol, respectively. Median age and oxygenation index was 1.5 years (0.4-5.3 yr) and 10.9 years (7.0-18.6 yr), respectively. There was no difference in 60-day mortality between LPMV and non-LPMV protocol groups (65/285 [22.8%] vs. 115/406 [28.3%]; p = 0.104). However, total adherence score did improve in the LPMV compared to non-LPMV group (57.1 [40.0-66.7] vs. 47.6 [31.0-58.3]; p < 0·001). After adjusting for confounders, adherence to LPMV strategies (adjusted hazard ratio, 0.98; 95% CI, 0.97-0.99; p = 0.004) but not the LPMV protocol itself was associated with a reduced risk of 60-day mortality. Adherence to PIP, DP, and PEEP/Fio2 combinations were associated with reduced mortality. CONCLUSIONS Adherence to LPMV elements over the first week of PARDS was associated with reduced mortality. Future work is needed to improve implementation of LPMV in order to improve adherence.
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Affiliation(s)
- Judith Ju Ming Wong
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Hongxing Dang
- Children's Hospital of Chongqing Medical University, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
| | - Chin Seng Gan
- Department of Paediatrics, University Malaya Medical Centre, University Malaya, Kuala Lumpur, Malaysia
| | - Phuc Huu Phan
- Vietnam National Children's Hospital, Hanoi, Vietnam
| | | | - Kazunori Aoki
- Hyogo Prefectural Kobe Children's Hospital, Hyogo, Japan
| | - Siew Wah Lee
- Sultanah Aminah Hospital, Johor, Malaysia
- Hospital Tengku Ampuan Rahimah, Selangor, Malaysia
| | | | - Lijia Fan
- Division of Paediatric Critical Care, National University Hospital, Singapore
| | - Chian Wern Tai
- Universiti Kebangsaan Malaysia Specialist Children's Hospital, Kuala Lumpur, Malaysia
| | - Soo Lin Chuah
- Department of Paediatrics, University Malaya Medical Centre, University Malaya, Kuala Lumpur, Malaysia
| | - Pei Chuen Lee
- Universiti Kebangsaan Malaysia Specialist Children's Hospital, Kuala Lumpur, Malaysia
| | | | - Louise Ngu
- Sarawak General Hospital, Sarawak, Malaysia
| | | | - Chunfeng Liu
- Shengjing Hospital of China Medical University, Liaoning, China
| | - Wei Xu
- Shengjing Hospital of China Medical University, Liaoning, China
| | - Dyah Kanya Wati
- Pediatric Emergency and Intensive Care Unit, Prof I.G.N.G Ngoerah Hospital, Bali, Indonesia
- Medical Faculty, Udayana University, Bali, Indonesia
| | - Suparyatha Ida Bagus Gede
- Pediatric Emergency and Intensive Care Unit, Prof I.G.N.G Ngoerah Hospital, Bali, Indonesia
- Medical Faculty, Udayana University, Bali, Indonesia
| | | | - Felix Liauw
- Harapan Kita National Women and Children Health Center, Jakarta, Indonesia
| | | | - Li Huang
- Guangzhou Women and Children's Medical Center, Guangdong, China
| | - Jia Yueh Chong
- Hospital Tunku Azizah Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Xuemei Zhu
- Children's Hospital of Fudan University, Shanghai, China
| | - Kam Lun Ellis Hon
- Paediatric Intensive Care Unit, Hong Kong Children's Hospital, Hong Kong Special Administrative Region, China
| | - Karen Ka Yan Leung
- Paediatric Intensive Care Unit, Hong Kong Children's Hospital, Hong Kong Special Administrative Region, China
| | - Rujipat Samransamruajkit
- Division of Pediatric Critical Care, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Yin Bun Cheung
- Duke-NUS Medical School, Singapore
- Tampere Center for Child, Adolescent and Maternal Health Research, Tampere University, Tampere, Finland
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
- Duke-NUS Medical School, Singapore
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9
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Colleti J, Lima-Setta F. Waiting for the Pediatric Acute Lung Injury Consensus Conference 3. CRITICAL CARE SCIENCE 2024; 36:e20240114en. [PMID: 38922238 PMCID: PMC11152441 DOI: 10.62675/2965-2774.20240114-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 04/15/2024] [Indexed: 06/27/2024]
Affiliation(s)
- José Colleti
- Hospital Israelita Albert EinteinSão PauloSPBrazilHospital Israelita Albert Eintein - São Paulo (SP), Brazil.
- Hospital da Luz Vila MarianaSão PauloSPBrazilHospital da Luz Vila Mariana - São Paulo (SP), Brazil.
| | - Fernanda Lima-Setta
- FIOCRUZInstituto Nacional da Saúde da Mulher, da Criança e do Adolescente Fernandes FigueiraRio de JaneiroRJBrazilInstituto Nacional da Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira - FIOCRUZ - Rio de Janeiro (RJ), Brazil.
- Instituto D'Or de Pesquisa e EnsinoRio de JaneiroRJBrazilInstituto D'Or de Pesquisa e Ensino - Rio de Janeiro (RJ), Brazil.
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10
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O'Hara JE, Graham RJ. Pediatric pulmonology year in review-Pediatric pulmonary critical care. Pediatr Pulmonol 2024. [PMID: 38888167 DOI: 10.1002/ppul.27116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 05/24/2024] [Accepted: 05/28/2024] [Indexed: 06/20/2024]
Abstract
Pediatric pulmonary critical care literature has continued to grow in recent years. Our aim in this review is to narrowly focus on publications providing clinically-relevant advances in pediatric pulmonary critical care in 2023.
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Affiliation(s)
- Jill E O'Hara
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Robert J Graham
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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11
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Killien EY, Ohman RT, Dervan LA, Smith MB, Rivara FP, Watson RS. Pediatric Acute Respiratory Distress Syndrome Severity and Health-Related Quality of Life Outcomes: Single-Center Retrospective Cohort, 2011-2017. Pediatr Crit Care Med 2024:00130478-990000000-00349. [PMID: 38832835 DOI: 10.1097/pcc.0000000000003552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
OBJECTIVES To determine factors associated with health-related quality of life (HRQL) decline among pediatric acute respiratory distress syndrome (PARDS) survivors. DESIGN Retrospective cohort study. SETTING Academic children's hospital. PATIENTS Three hundred fifteen children 1 month to 18 years old with an unplanned PICU admission from December 2011 to February 2017 enrolled in the hospital's Outcomes Assessment Program. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Pre-admission baseline and median 6-week post-discharge HRQL were assessed using the Pediatric Quality of Life Inventory or the Functional Status II-R. Patients meeting retrospectively applied Second Pediatric Acute Lung Injury Consensus Conference criteria for PARDS were identified, and PARDS severity was classified using binary (mild/moderate, severe) and trichotomous (mild, moderate, severe) categorization for noninvasive ventilation and invasive mechanical ventilation (IMV). PARDS occurred in 41 of 315 children (13.0%). Clinically important HRQL decline (≥ 4.5 points) occurred in 17 of 41 patients (41.5%) with PARDS and 64 of 274 without PARDS (23.4%). On multivariable generalized linear regression adjusted for age, baseline Pediatric Overall Performance Category, maximum nonrespiratory Pediatric Logistic Organ Dysfunction score, diagnosis, length of stay, and time to follow-up, PARDS was associated with HRQL decline (adjusted relative risk [aRR], 1.70; 95% CI, 1.03-2.77). Four-hour and maximum PARDS severity were the only factors associated with HRQL decline. HRQL decline occurred in five of 18 patients with mild PARDS at 4 hours, five of 13 with moderate PARDS (aRR 2.35 vs. no PARDS [95% CI, 1.01-5.50]), and seven of ten with severe PARDS (aRR 2.56 vs. no PARDS [95% CI, 1.45-4.53]). The area under the receiver operating characteristic curve for discrimination of HRQL decline for IMV patients was 0.79 (95% CI, 0.66-0.91) for binary and 0.80 (95% CI, 0.69-0.93) for trichotomous severity categorization. CONCLUSIONS HRQL decline is common among children surviving PARDS, and risk of decline is associated with PARDS severity. HRQL decline from baseline may be an efficient and clinically meaningful endpoint to incorporate into PARDS clinical trials.
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Affiliation(s)
- Elizabeth Y Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Center for Child Health, Behavior, & Development, Seattle Children's Research Institute, Seattle, WA
| | - Robert T Ohman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
| | - Leslie A Dervan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Center for Clinical & Translational Research, Seattle Children's Research Institute, Seattle, WA
| | - Mallory B Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Frederick P Rivara
- Center for Child Health, Behavior, & Development, Seattle Children's Research Institute, Seattle, WA
- Division of General Pediatrics, Department of Pediatrics, University of Washington, Seattle, WA
| | - R Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Center for Child Health, Behavior, & Development, Seattle Children's Research Institute, Seattle, WA
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12
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Tasker RC. Editor's Choice Articles for June. Pediatr Crit Care Med 2024; 25:489-492. [PMID: 38836708 DOI: 10.1097/pcc.0000000000003530] [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: 06/06/2024]
Affiliation(s)
- Robert C Tasker
- orcid.org/0000-0003-3647-8113
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Selwyn College, Cambridge University, Cambridge, United Kingdom
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13
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Xinhui W, Long X. Pediatric ARDS after Car-T therapy. Pediatr Pulmonol 2024; 59:1775-1776. [PMID: 38545997 DOI: 10.1002/ppul.26992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 03/13/2024] [Accepted: 03/15/2024] [Indexed: 05/28/2024]
Affiliation(s)
- Wang Xinhui
- Department of Pediatric Critical Care Medicine, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Road, Shanghai, 200127, Pudong New District, China
| | - Xiang Long
- Department of Pediatric Critical Care Medicine, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Road, Shanghai, 200127, Pudong New District, China
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14
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Weinstein R, Naber CE, Brumme K. Revisiting dexamethasone use in the pediatric emergency department. Curr Opin Pediatr 2024; 36:251-255. [PMID: 38655807 DOI: 10.1097/mop.0000000000001351] [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: 04/26/2024]
Abstract
PURPOSE OF REVIEW Dexamethasone is an essential treatment for common pediatric inflammatory, airway, and respiratory conditions. We aim to provide up-to-date recommendations for treatment of anaphylaxis, croup, coronavirus disease, multisystem inflammatory syndrome in children, and asthma with dexamethasone for use in the pediatric emergency department. RECENT FINDINGS Literature largely continues to support the use of dexamethasone in most of the above conditions, however, recommendations for dosing and duration are evolving. SUMMARY The findings discussed in this review will enable pediatric emergency medicine providers to use dexamethasone effectively as treatment of common pediatric conditions and minimize the occurrence of side-effects caused by gratuitous corticosteroid use.
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Affiliation(s)
- Rebecca Weinstein
- Massachusetts General Hospital, 55 Fruit Street Boston, Massachusetts, USA
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Kneyber MCJ, Cheifetz IM, Asaro LA, Graves TL, Viele K, Natarajan A, Wypij D, Curley MAQ. Protocol for the Prone and Oscillation Pediatric Clinical Trial (PROSpect). Pediatr Crit Care Med 2024:00130478-990000000-00347. [PMID: 38801306 DOI: 10.1097/pcc.0000000000003541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
OBJECTIVES Respiratory management for pediatric acute respiratory distress syndrome (PARDS) remains largely supportive without data to support one approach over another, including supine versus prone positioning (PP) and conventional mechanical ventilation (CMV) versus high-frequency oscillatory ventilation (HFOV). DESIGN We present the research methodology of a global, multicenter, two-by-two factorial, response-adaptive, randomized controlled trial of supine versus PP and CMV versus HFOV in high moderate-severe PARDS, the Prone and Oscillation Pediatric Clinical Trial (PROSpect, www.ClinicalTrials.gov, NCT03896763). SETTING Approximately 60 PICUs with on-site extracorporeal membrane oxygenation support in North and South America, Europe, Asia, and Oceania with experience using PP and HFOV in the care of patients with PARDS. PATIENTS Eligible pediatric patients (2 wk old or older and younger than 21 yr) are randomized within 48 h of meeting eligibility criteria occurring within 96 h of endotracheal intubation. INTERVENTIONS One of four arms, including supine/CMV, prone/CMV, supine/HFOV, or prone/HFOV. We hypothesize that children with high moderate-severe PARDS treated with PP or HFOV will demonstrate greater than or equal to 2 additional ventilator-free days (VFD). MEASUREMENTS AND MAIN RESULTS The primary outcome is VFD through day 28; nonsurvivors receive zero VFD. Secondary and exploratory outcomes include nonpulmonary organ failure-free days, interaction effects of PP with HFOV on VFD, 90-day in-hospital mortality, and among survivors, duration of mechanical ventilation, PICU and hospital length of stay, and post-PICU functional status and health-related quality of life. Up to 600 patients will be randomized, stratified by age group and direct/indirect lung injury. Adaptive randomization will first occur 28 days after 300 patients are randomized and every 100 patients thereafter. At these randomization updates, new allocation probabilities will be computed based on intention-to-treat trial results, increasing allocation to well-performing arms and decreasing allocation to poorly performing arms. Data will be analyzed per intention-to-treat for the primary analyses and per-protocol for primary, secondary, and exploratory analyses. CONCLUSIONS PROSpect will provide clinicians with data to inform the practice of PP and HFOV in PARDS.
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Affiliation(s)
- Martin C J Kneyber
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Critical Care, Anesthesiology, Peri-operative and Emergency Medicine (CAPE), University of Groningen, Groningen, The Netherlands
| | - Ira M Cheifetz
- Division of Cardiac Critical Care, Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Lisa A Asaro
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | | | | | - Aruna Natarajan
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - David Wypij
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Martha A Q Curley
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA
- Anesthesia and Critical Care Medicine-Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA
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16
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Bhalla AK, Klein MJ, Hotz J, Kwok J, Bonilla-Cartagena JE, Baron DA, Kohler K, Bornstein D, Chang D, Vu K, Armenta-Quiroz A, Nelson LP, Newth CJL, Khemani RG. Noninvasive Surrogate for Physiologic Dead Space Using the Carbon Dioxide Ventilatory Equivalent: Testing in a Single-Center Cohort, 2017-2023. Pediatr Crit Care Med 2024:00130478-990000000-00344. [PMID: 38771137 DOI: 10.1097/pcc.0000000000003539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
OBJECTIVES We sought to evaluate the association between the carbon dioxide (co2) ventilatory equivalent (VEqco2 = minute ventilation/volume of co2 produced per min), a marker of dead space that does not require a blood gas measurement, and mortality risk. We compared the strength of this association to that of physiologic dead space fraction (VD/Vt = [Paco2-mixed-expired Pco2]/Paco2) as well as to other commonly used markers of dead space (i.e., the end-tidal alveolar dead space fraction [AVDSf = (Paco2-end-tidal Pco2)/Paco2], and ventilatory ratio [VR = (minute ventilation × Paco2)/(age-adjusted predicted minute ventilation × 37.5)]). DESIGN Retrospective cohort data, 2017-2023. SETTING Quaternary PICU. PATIENTS One hundred thirty-one children with acute respiratory distress syndrome. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS All dead space markers were calculated at the same 1-minute timepoint for each patient within the first 72 hours of using invasive mechanical ventilation. The 131 children had a median (interquartile range, IQR) age of 5.8 (IQR 1.4, 12.6) years, oxygenation index (OI) of 7.5 (IQR 4.6, 14.3), VD/Vt of 0.47 (IQR 0.38, 0.61), and mortality was 17.6% (23/131). Higher VEqco2 (p = 0.003), VD/Vt (p = 0.002), and VR (p = 0.013) were all associated with greater odds of mortality in multivariable models adjusting for OI, immunosuppressive comorbidity, and overall severity of illness. We failed to identify an association between AVDSf and mortality in the multivariable modeling. Similarly, we also failed to identify an association between OI and mortality after controlling for any dead space marker in the modeling. For the 28-day ventilator-free days outcome, we failed to identify an association between VD/Vt and the dead space markers in multivariable modeling, although OI was significant. CONCLUSIONS VEqco2 performs similarly to VD/Vt and other surrogate dead space markers, is independently associated with mortality risk, and may be a reasonable noninvasive surrogate for VD/Vt.
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Affiliation(s)
- Anoopindar K Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Margaret J Klein
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Justin Hotz
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Jeni Kwok
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | | | - David A Baron
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Kristen Kohler
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Dinnel Bornstein
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Daniel Chang
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Kennedy Vu
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Anabel Armenta-Quiroz
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Lara P Nelson
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Christopher J L Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
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17
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Agarwal A, Jayashree M, Angurana SK, Sharma R, Ghosh A, Singh MP, Nallasamy K, Bansal A. Clinical Profile, Intensive Care Needs and Predictors of Outcome Among Children Admitted with Non-COVID Severe Acute Respiratory Illness (SARI) During the Pandemic. Indian J Pediatr 2024; 91:329-336. [PMID: 37870740 DOI: 10.1007/s12098-023-04860-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 08/28/2023] [Indexed: 10/24/2023]
Abstract
OBJECTIVES To study the epidemiology of non-coronavirus disease-2019 (non-COVID-19) respiratory viral infections with respect to their clinical profile, intensive care needs and predictors of outcome once the non-pharmacological interventions (NPI) during the coronavirus disease-2019 (COVID-19) pandemic were relaxed. METHODS Retrospective analysis of children with Severe Acute Respiratory Illness (SARI) who were SARS-CoV-2 negative, admitted to the Pediatric Emergency/Intensive Care Unit (PICU) from July 2021 through October 2021 was conducted. RESULTS One hundred and thirty nine children with median age of 11 (4-28.5) mo were included. Besides respiratory symptoms in all, diarrhea was reported in 90 (64.7%) children. Nearly half (n = 66; 47%) presented in hypoxemic respiratory failure (SpO2 <88%). Fifty-two (37.4%) children had co-morbidities, commonest being congenital heart disease in 12 (23.1%). Baseline parameters revealed leukopenia (specifically lymphopenia) 39 (28%), elevated aspartate transaminase [Serum glutamic-oxaloacetic transaminase (SGOT)] in 108 (77.6%), elevated N-acetyl-cysteine-activated creatinine kinase (CK-NAC) 23 (79%) and lactate dehydrogenase (LDH) 15 (88%). Intensive care needs included mechanical ventilation 51 (36.6%), vasoactive support 34 (24.5%), and renal replacement therapy 10 (7.1%). Forty-two (30.2%) children developed multi-organ dysfunction syndrome (MODS). One hundred and three (74.1%) children were discharged, 31 (22.3%) died, and 5 (3.6%) left against medical advice. On multivariate regression analysis, elevated liver enzymes (>5 times normal), hypoxemic respiratory failure at admission, hypotensive shock and MODS predicted mortality. CONCLUSIONS A surge in non-COVID SARI was observed once lockdown measures were relaxed. Nearly 1/3rd progressed to multi-organ failure and died. Elevated liver enzymes, hypoxemic respiratory failure at admission, hypotensive shock and MODS predicted death.
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Affiliation(s)
- Ashish Agarwal
- Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre (APC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Muralidharan Jayashree
- Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre (APC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - Suresh Kumar Angurana
- Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre (APC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Raman Sharma
- Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre (APC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Arnab Ghosh
- Department of Virology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Mini P Singh
- Department of Virology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Karthi Nallasamy
- Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre (APC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Arun Bansal
- Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre (APC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Marraro GA, Chen YF, Spada C. So, What About Acute Respiratory Distress Syndrome in Immunocompromised Pediatric Patients? Pediatr Crit Care Med 2024; 25:375-377. [PMID: 38573039 DOI: 10.1097/pcc.0000000000003448] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Affiliation(s)
- Giuseppe A Marraro
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
- Healthcare Accountability Lab, University of Milan, Milan, Italy
| | - Yun-Feng Chen
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
| | - Claudio Spada
- Healthcare Accountability Lab, University of Milan, Milan, Italy
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Patel BM, Reilly JP, Bhalla AK, Smith LS, Khemani RG, Jones TK, Meyer NJ, Harhay MO, Yehya N. Association between Age and Mortality in Pediatric and Adult Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2024; 209:871-878. [PMID: 38306669 PMCID: PMC10995578 DOI: 10.1164/rccm.202310-1926oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/02/2024] [Indexed: 02/04/2024] Open
Abstract
Rationale: The epidemiology, management, and outcomes of acute respiratory distress syndrome (ARDS) differ between children and adults, with lower mortality rates in children despite comparable severity of hypoxemia. However, the relationship between age and mortality is unclear.Objective: We aimed to define the association between age and mortality in ARDS, hypothesizing that it would be nonlinear.Methods: We performed a retrospective cohort study using data from two pediatric ARDS observational cohorts (n = 1,236), multiple adult ARDS trials (n = 5,547), and an adult observational ARDS cohort (n = 1,079). We aligned all datasets to meet Berlin criteria. We performed unadjusted and adjusted logistic regression using fractional polynomials to assess the potentially nonlinear relationship between age and 90-day mortality, adjusting for sex, PaO2/FiO2, immunosuppressed status, year of study, and observational versus randomized controlled trial, treating each individual study as a fixed effect.Measurements and Main Results: There were 7,862 subjects with median ages of 4 years in the pediatric cohorts, 52 years in the adult trials, and 61 years in the adult observational cohort. Most subjects (43%) had moderate ARDS by Berlin criteria. Ninety-day mortality was 19% in the pediatric cohorts, 33% in the adult trials, and 67% in the adult observational cohort. We found a nonlinear relationship between age and mortality, with mortality risk increasing at an accelerating rate between 11 and 65 years of age, after which mortality risk increased more slowly.Conclusions: There was a nonlinear relationship between age and mortality in pediatric and adult ARDS.
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Affiliation(s)
- Bhavesh M Patel
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - John P Reilly
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
- Center for Translational Lung Biology, and
| | - Anoopindar K Bhalla
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California; and
| | - Lincoln S Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Robinder G Khemani
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California; and
| | - Tiffanie K Jones
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
- Center for Translational Lung Biology, and
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nuala J Meyer
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
- Center for Translational Lung Biology, and
| | - Michael O Harhay
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nadir Yehya
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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20
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Cruces P, Reveco S, Caviedes P, Díaz F. Respiratory System Compliance Accurately Assesses the "Baby Lung" in Pediatric Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2024; 209:890-893. [PMID: 38324072 PMCID: PMC10995576 DOI: 10.1164/rccm.202310-1890le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 02/06/2024] [Indexed: 02/08/2024] Open
Affiliation(s)
- Pablo Cruces
- Unidad de Paciente Crítico Pediátrico, Departamento de Pediatría, Hospital El Carmen de Maipú, Santiago, Chile
- Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network); and
| | - Sonia Reveco
- Unidad de Paciente Crítico Pediátrico, Departamento de Pediatría, Hospital El Carmen de Maipú, Santiago, Chile
| | - Paola Caviedes
- Unidad de Paciente Crítico Pediátrico, Departamento de Pediatría, Hospital El Carmen de Maipú, Santiago, Chile
| | - Franco Díaz
- Unidad de Paciente Crítico Pediátrico, Departamento de Pediatría, Hospital El Carmen de Maipú, Santiago, Chile
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network); and
- Unidad de Investigación y Epidemiología Clínica, Escuela de Medicina, Universidad Finis Terrae, Santiago, Chile
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21
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Tasker RC. Editor's Choice Articles for April. Pediatr Crit Care Med 2024; 25:285-287. [PMID: 38573038 DOI: 10.1097/pcc.0000000000003501] [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: 04/05/2024]
Affiliation(s)
- Robert C Tasker
- orcid.org/0000-0003-3647-8113
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Selwyn College, Cambridge University, Cambridge, United Kingdom
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Schmidt EP, Randolph AG. Adolescents and Young Adults: An Understudied, yet Likely Informative, Population in ARDS. Am J Respir Crit Care Med 2024; 209:785-786. [PMID: 38387007 PMCID: PMC10995567 DOI: 10.1164/rccm.202402-0304ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 02/22/2024] [Indexed: 02/24/2024] Open
Affiliation(s)
- Eric P Schmidt
- Division of Pulmonary and Critical Care Medicine Massachusetts General Hospital and Harvard Medical School Boston, Massachusetts
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine Boston Children's Hospital Boston, Massachusetts
- Departments of Anaesthesia and Pediatrics Harvard Medical School Boston, Massachusetts
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23
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Wong JJM, Tan HL, Sultana R, Ma YJ, Aguilan AB, Goh CY, Lee WC, Kumar P, Lee JH. Respiratory Support After Extubation in Children With Pediatric ARDS. Respir Care 2024; 69:422-429. [PMID: 38538015 PMCID: PMC11108100 DOI: 10.4187/respcare.11334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2024]
Abstract
BACKGROUND Postextubation respiratory support in pediatric ARDS may be used to support the recovering respiratory system and promote timely, successful liberation from mechanical ventilation. This study's aims were to (1) describe the use of postextubation respiratory support in pediatric ARDS from the time of extubation to hospital discharge, (2) identify potential risk factors for postextubation respiratory support, and (3) provide preliminary data for future larger studies. METHODS This pilot single-center prospective cohort study recruited subjects with pediatric ARDS. Subjects' respiratory status up to hospital discharge, the use of postextubation respiratory support, and how it changed over time were recorded. Analysis was performed comparing subjects who received postextubation respiratory support versus those who did not and compared its use among pediatric ARDS severity categories. Multivariable logistic regression was used to determine variables associated with the use of postextubation respiratory support and included oxygenation index (OI), ventilator duration, and weight. RESULTS Seventy-three subjects with pediatric ARDS, with median age and OI of 4 (0.6-10.5) y and 7.3 (4.9-12.7), respectively, were analyzed. Postextubation respiratory support was provided to 54/73 (74%) subjects: 28/45 (62.2%), 19/21 (90.5%), and 7/7 (100%) for mild, moderate, and severe pediatric ARDS, respectively, (P = .01). OI and mechanical ventilation duration were higher in subjects who received postextubation respiratory support (8.7 [5.4-14] vs 4.6 [3.7-7], P < .001 and 10 [7-17] d vs 4 [2-7] d, P < .001) compared to those who did not. At hospital discharge, 12/67 (18.2%) survivors received home respiratory support (6 subjects died prior to hospital discharge). In the multivariable model, ventilator duration (adjusted odds ratio 1.3 [95% CI 1.0-1.7], P = .050) and weight (adjusted odds ratio 0.95 [95% CI 0.91-0.99], P = .02) were associated with the use of postextubation respiratory support. CONCLUSIONS The majority of intubated subjects with pediatric ARDS received respiratory support postextubation, and a substantial proportion continued to require it up to hospital discharge.
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Affiliation(s)
- Judith Ju Ming Wong
- Drs Wong and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore; and Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore. Mss Tan, Ma, and Goh and Messrs Aguilan and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore. Ms Sultana is affiliated with Center for Quantitative Medicine, Duke-NUS Medical School, Singapore. Dr Kumar is affiliated with Translational Immunology Institute, SingHealth/Duke-NUS Academic Medical Centre, Singapore.
| | - Herng Lee Tan
- Drs Wong and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore; and Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore. Mss Tan, Ma, and Goh and Messrs Aguilan and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore. Ms Sultana is affiliated with Center for Quantitative Medicine, Duke-NUS Medical School, Singapore. Dr Kumar is affiliated with Translational Immunology Institute, SingHealth/Duke-NUS Academic Medical Centre, Singapore
| | - Rehena Sultana
- Drs Wong and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore; and Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore. Mss Tan, Ma, and Goh and Messrs Aguilan and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore. Ms Sultana is affiliated with Center for Quantitative Medicine, Duke-NUS Medical School, Singapore. Dr Kumar is affiliated with Translational Immunology Institute, SingHealth/Duke-NUS Academic Medical Centre, Singapore
| | - Yi-Jyun Ma
- Drs Wong and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore; and Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore. Mss Tan, Ma, and Goh and Messrs Aguilan and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore. Ms Sultana is affiliated with Center for Quantitative Medicine, Duke-NUS Medical School, Singapore. Dr Kumar is affiliated with Translational Immunology Institute, SingHealth/Duke-NUS Academic Medical Centre, Singapore
| | - Apollo Bugarin Aguilan
- Drs Wong and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore; and Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore. Mss Tan, Ma, and Goh and Messrs Aguilan and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore. Ms Sultana is affiliated with Center for Quantitative Medicine, Duke-NUS Medical School, Singapore. Dr Kumar is affiliated with Translational Immunology Institute, SingHealth/Duke-NUS Academic Medical Centre, Singapore
| | - Chen Yun Goh
- Drs Wong and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore; and Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore. Mss Tan, Ma, and Goh and Messrs Aguilan and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore. Ms Sultana is affiliated with Center for Quantitative Medicine, Duke-NUS Medical School, Singapore. Dr Kumar is affiliated with Translational Immunology Institute, SingHealth/Duke-NUS Academic Medical Centre, Singapore
| | - Wen Cong Lee
- Drs Wong and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore; and Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore. Mss Tan, Ma, and Goh and Messrs Aguilan and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore. Ms Sultana is affiliated with Center for Quantitative Medicine, Duke-NUS Medical School, Singapore. Dr Kumar is affiliated with Translational Immunology Institute, SingHealth/Duke-NUS Academic Medical Centre, Singapore
| | - Pavanish Kumar
- Drs Wong and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore; and Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore. Mss Tan, Ma, and Goh and Messrs Aguilan and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore. Ms Sultana is affiliated with Center for Quantitative Medicine, Duke-NUS Medical School, Singapore. Dr Kumar is affiliated with Translational Immunology Institute, SingHealth/Duke-NUS Academic Medical Centre, Singapore
| | - Jan Hau Lee
- Drs Wong and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore; and Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore. Mss Tan, Ma, and Goh and Messrs Aguilan and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore. Ms Sultana is affiliated with Center for Quantitative Medicine, Duke-NUS Medical School, Singapore. Dr Kumar is affiliated with Translational Immunology Institute, SingHealth/Duke-NUS Academic Medical Centre, Singapore
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24
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Morabito LA, Corica D, Pepe G, Li Pomi A, Aversa T, Wasniewska MG. Critical illness-related corticosteroid insufficiency (CIRCI) in paediatric patients: a diagnostic and therapeutic challenge. Ital J Pediatr 2024; 50:46. [PMID: 38462639 PMCID: PMC10926569 DOI: 10.1186/s13052-024-01616-x] [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: 11/09/2023] [Accepted: 02/24/2024] [Indexed: 03/12/2024] Open
Abstract
Critical illness-related corticosteroid insufficiency or CIRCI is characterized by acute and life-threatening disfunction of hypothalamic-pituitary-adrenal (HPA) axis observed among intensive care unit- staying patients.It is associated with increased circulating levels of biological markers of inflammation and coagulation, morbidity, length of ICU stay, and mortality.Several mechanisms are involved in CIRCI pathogenesis: reduced CRH-stimulated ACTH release, peripheral resistance to glucocorticoids, altered cortisol synthesis, impaired cortisol-free fraction and bioavailability.Diagnostic and therapeutic management of this condition in children is still debated, probably because of the lack of agreement among intensive care specialists and endocrinologists regarding diagnostic criteria and prevalence of CIRCI in paediatric age.In the present narrative review, we focused on definition of CIRCI in paediatric age and we advise on how to diagnose and treat this poorly understood condition, based on current literature data.
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Affiliation(s)
- Letteria Anna Morabito
- Pediatric Unit, Maternal Infant Department, "Gaetano Martino" University Hospital, Via Consolare Valeria, 98122, Messina, Italy.
| | - Domenico Corica
- Pediatric Unit, Maternal Infant Department, "Gaetano Martino" University Hospital, Via Consolare Valeria, 98122, Messina, Italy
- Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy
| | - Giorgia Pepe
- Pediatric Unit, Maternal Infant Department, "Gaetano Martino" University Hospital, Via Consolare Valeria, 98122, Messina, Italy
- Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy
| | - Alessandra Li Pomi
- Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy
| | - Tommaso Aversa
- Pediatric Unit, Maternal Infant Department, "Gaetano Martino" University Hospital, Via Consolare Valeria, 98122, Messina, Italy
- Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy
| | - Malgorzata Gabriela Wasniewska
- Pediatric Unit, Maternal Infant Department, "Gaetano Martino" University Hospital, Via Consolare Valeria, 98122, Messina, Italy
- Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy
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25
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de Farias ECF, Pavão Junior MJC, de Sales SCD, do Nascimento LMPP, Pavão DCA, Pinheiro APS, Pinheiro AHO, Alves MCB, Ferraro KMMM, Aires LFQ, Dias LG, Machado MMM, Serrão MJD, Gomes RR, de Moraes SMP, Moura GMG, de Sousa AMB, Pontes GCL, Carvalho RDFP, Silva CTC, Lemes G, da C G Diniz B, Chermont AG, de Almeida KFS, Saraty SB, Maia MLF, Lima MRC, Carvalho PB, de B Braga R, de O Harada K, Justino MCA, Clemente G, Terreri MT, Monteiro MC. Factors associated to mortality in children with critical COVID-19 and multisystem inflammatory syndrome in a resource-poor setting. Sci Rep 2024; 14:5539. [PMID: 38448485 PMCID: PMC10918095 DOI: 10.1038/s41598-024-55065-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 02/20/2024] [Indexed: 03/08/2024] Open
Abstract
SARS-CoV-2 infection in children is usually asymptomatic/mild. However, some patients may develop critical forms. We aimed to describe characteristics and evaluate the factors associated to in-hospital mortality of patients with critical COVID-19/MIS-C in the Amazonian region. This multicenter prospective cohort included critically ill children (1 mo-18 years old), with confirmed COVID-19/MIS-C admitted to 3 tertiary Pediatric Intensive Care Units (PICU) in the Brazilian Amazon, between April/2020 and May/2023. The main outcome was in-hospital mortality and were evaluated using a multivariable Cox proportional regression. We adjusted the model for pediatric risk of mortality score version IV (PRISMIV) score and age/comorbidity. 266 patients were assessed with 187 in the severe COVID-19 group, 79 included in the MIS-C group. In the severe COVID-19 group 108 (57.8%) were male, median age was 23 months, 95 (50.8%) were up to 2 years of age. Forty-two (22.5%) patients in this group died during follow-up in a median time of 11 days (IQR, 2-28). In the MIS-C group, 56 (70.9%) were male, median age was 23 months and median follow-up was 162 days (range, 3-202). Death occurred in 17 (21.5%) patients with a median death time of 7 (IQR, 4-13) days. The mortality was associated with higher levels of Vasoactive Inotropic-Score (VIS), presence of acute respiratory distress syndrome (ARDS), higher levels of Erythrocyte Sedimentation Rate, (ESR) and thrombocytopenia. Critically ill patients with severe COVID-19 and MIS-C from the Brazilian Amazon showed a high mortality rate, within 12 days of hospitalization.
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Affiliation(s)
- Emmerson C F de Farias
- Division of Pediatric Intensive Care, Department of Pediatrics, Fundação Santa Casa de Misericórdia do Pará, Belém, PA, Brazil.
- Department of Pediatric Critical Care, Fundação Santa Casa de Misericórdia do Pará, 7th Floor, St. Bernal do Couto, 988 - Umarizal, Belém, PA, 66055-080, Brazil.
| | - Manoel J C Pavão Junior
- Division of Pediatric Intensive Care, Department of Pediatrics, Fundação Santa Casa de Misericórdia do Pará, Belém, PA, Brazil
| | - Susan C D de Sales
- Division of Pediatric Intensive Care, Department of Pediatrics, Fundação Santa Casa de Misericórdia do Pará, Belém, PA, Brazil
| | - Luciana M P P do Nascimento
- Division of Pediatric Intensive Care, Department of Pediatrics, Fundação Santa Casa de Misericórdia do Pará, Belém, PA, Brazil
| | - Dalila C A Pavão
- Division of Pediatric Intensive Care, Department of Pediatrics, Fundação Santa Casa de Misericórdia do Pará, Belém, PA, Brazil
| | - Anna P S Pinheiro
- Division of Pediatric Intensive Care, Department of Pediatrics, Fundação Santa Casa de Misericórdia do Pará, Belém, PA, Brazil
| | - Andreza H O Pinheiro
- Division of Pediatric Intensive Care, Department of Pediatrics, Fundação Santa Casa de Misericórdia do Pará, Belém, PA, Brazil
| | - Marília C B Alves
- Division of Pediatric Intensive Care, Department of Pediatrics, Fundação Santa Casa de Misericórdia do Pará, Belém, PA, Brazil
| | - Kíssila M M M Ferraro
- Division of Pediatric Intensive Care, Department of Pediatrics, Fundação Santa Casa de Misericórdia do Pará, Belém, PA, Brazil
| | - Larisse F Q Aires
- Division of Pediatric Intensive Care, Department of Pediatrics, Fundação Santa Casa de Misericórdia do Pará, Belém, PA, Brazil
| | - Luana G Dias
- Division of Pediatric Intensive Care, Department of Pediatrics, Fundação Santa Casa de Misericórdia do Pará, Belém, PA, Brazil
| | - Mayara M M Machado
- Division of Pediatric Intensive Care, Department of Pediatrics, Fundação Santa Casa de Misericórdia do Pará, Belém, PA, Brazil
| | - Michaelle J D Serrão
- Division of Pediatric Intensive Care, Department of Pediatrics, Fundação Santa Casa de Misericórdia do Pará, Belém, PA, Brazil
| | - Raphaella R Gomes
- Division of Pediatric Intensive Care, Department of Pediatrics, Fundação Santa Casa de Misericórdia do Pará, Belém, PA, Brazil
| | - Sara M P de Moraes
- Division of Pediatric Intensive Care, Department of Pediatrics, Fundação Santa Casa de Misericórdia do Pará, Belém, PA, Brazil
| | - Gabriella M G Moura
- Division of Pediatric Intensive Care, Department of Pediatrics, Fundação Santa Casa de Misericórdia do Pará, Belém, PA, Brazil
| | - Adriana M B de Sousa
- Division of Pediatric Intensive Care, Department of Pediatrics, Fundação Santa Casa de Misericórdia do Pará, Belém, PA, Brazil
| | - Gabriela C L Pontes
- Division of Pediatric Intensive Care, Department of Pediatrics, Fundação Santa Casa de Misericórdia do Pará, Belém, PA, Brazil
| | - Railana D F P Carvalho
- Division of Pediatric Intensive Care, Department of Pediatrics, Fundação Santa Casa de Misericórdia do Pará, Belém, PA, Brazil
| | - Cristiane T C Silva
- Division of Pediatric Intensive Care, Department of Pediatrics, Fundação Santa Casa de Misericórdia do Pará, Belém, PA, Brazil
| | - Guilherme Lemes
- Division of Pediatric Intensive Care, Department of Pediatrics, Fundação Santa Casa de Misericórdia do Pará, Belém, PA, Brazil
| | - Bruna da C G Diniz
- Division of Pediatric Intensive Care, Department of Pediatrics, Fundação Santa Casa de Misericórdia do Pará, Belém, PA, Brazil
| | - Aurimery G Chermont
- Medical School, Medical Science Institute, Federal University of Pará/UFPA, Belém, PA, Brazil
| | - Kellen F S de Almeida
- Medical School, Medical Science Institute, Federal University of Pará/UFPA, Belém, PA, Brazil
| | - Salma B Saraty
- Division of Pediatric Intensive Care, Department of Pediatrics, Pronto Socorro Municipal Mário Pinotti's Hospital, Belém, PA, Brazil
| | - Mary L F Maia
- Division of Pediatric Intensive Care, Department of Pediatrics, Pronto Socorro Municipal Mário Pinotti's Hospital, Belém, PA, Brazil
| | - Miriam R C Lima
- Division of Pediatric Intensive Care, Department of Pediatrics, Pronto Socorro Municipal Mário Pinotti's Hospital, Belém, PA, Brazil
| | - Patricia B Carvalho
- Division of Pediatric Intensive Care, Departament of Pediatrics, Fundação Hospital das Clínicas Gaspar Viana, Belém, PA, Brazil
| | - Renata de B Braga
- Division of Pediatric Intensive Care, Departament of Pediatrics, Fundação Hospital das Clínicas Gaspar Viana, Belém, PA, Brazil
| | - Kathia de O Harada
- Division of Pediatric Intensive Care, Departament of Pediatrics, Fundação Hospital das Clínicas Gaspar Viana, Belém, PA, Brazil
| | - Maria C A Justino
- Instituto Evandro Chagas, Virology Section, Health Surveillance Secretariat, Brazilian Ministry of Health, Ananindeua, PA, Brazil
| | - Gleice Clemente
- Division of Pediatric Rheumatology, Department of Pediatrics, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Maria Teresa Terreri
- Division of Pediatric Rheumatology, Department of Pediatrics, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Marta C Monteiro
- Pharmaceutical Science Post-Graduation Program and Neuroscience and Cell Biology Graduate Program, Health Science Institute, Federal University of Pará/UFPA, Belém, PA, Brazil
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26
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Emeriaud G, López-Fernández YM, Khemani RG. The authors reply. Pediatr Crit Care Med 2024; 25:e169-e171. [PMID: 38451804 DOI: 10.1097/pcc.0000000000003438] [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: 03/09/2024]
Affiliation(s)
- Guillaume Emeriaud
- Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montréal, QC, Canada
| | - Yolanda M López-Fernández
- Pediatric Intensive Care Unit, Department of Pediatrics, Cruces University Hospital, Biocruces-Bizkaia Health Research Institute, Bizkaia, Spain
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
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27
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Kneyber MCJ. Positive end-expiratory pressure in the pediatric intensive care unit. Paediatr Respir Rev 2024; 49:5-8. [PMID: 38030513 DOI: 10.1016/j.prrv.2023.11.003] [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: 11/15/2023] [Accepted: 11/21/2023] [Indexed: 12/01/2023]
Abstract
Application of positive end-expiratory pressure (PEEP) targeted towards improving oxygenation is one of the components of the ventilatory management of pediatric acute respiratory distress syndrome (PARDS). Low end-expiratory airway pressures cause repetitive opening and closure of unstable alveoli, leading to surfactant dysfunction and parenchymal shear injury. Consequently, there is less lung volume available for tidal ventilation when there are atelectatic lung regions. This will increase lung strain in aerated lung areas to which the tidal volume is preferentially distributed. Pediatric critical care practitioners tend to use low levels of PEEP and inherently accept higher FiO2, but these practices may negatively affect patient outcome. The Pediatric Acute Lung Injury Consensus Conference (PALICC) suggests that PEEP should be titrated to oxygenation/oxygen delivery, hemodynamics, and compliance measured under static conditions as compared to other clinical parameters or any of these parameters in isolation in patients with PARDS, while limiting plateau pressure and/or driving pressure limits.
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Affiliation(s)
- Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; Anaesthesiology, Peri-operative & Emergency Medicine, University of Groningen, Groningen, the Netherlands.
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28
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Sallee CJ, Hippensteel JA, Miller KR, Oshima K, Pham AT, Richter RP, Belperio J, Sierra YL, Schwingshackl A, Mourani PM, Schmidt EP, Sapru A, Maddux AB. Endothelial Glycocalyx Degradation Patterns in Sepsis-Associated Pediatric Acute Respiratory Distress Syndrome: A Single Center Retrospective Observational Study. J Intensive Care Med 2024; 39:277-287. [PMID: 37670670 PMCID: PMC10845819 DOI: 10.1177/08850666231200162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/21/2023] [Accepted: 08/24/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND Sepsis-associated destruction of the pulmonary microvascular endothelial glycocalyx (EGCX) creates a vulnerable endothelial surface, contributing to the development of acute respiratory distress syndrome (ARDS). Constituents of the EGCX shed into circulation, glycosaminoglycans and proteoglycans, may serve as biomarkers of endothelial dysfunction. We sought to define the patterns of plasma EGCX degradation products in children with sepsis-associated pediatric ARDS (PARDS), and test their association with clinical outcomes. METHODS We retrospectively analyzed a prospective cohort (2018-2020) of children (≥1 month to <18 years of age) receiving invasive mechanical ventilation for acute respiratory failure for ≥72 h. Children with and without sepsis-associated PARDS were selected from the parent cohort and compared. Blood was collected at time of enrollment. Plasma glycosaminoglycan disaccharide class (heparan sulfate, chondroitin sulfate, and hyaluronan) and sulfation subtypes (heparan sulfate and chondroitin sulfate) were quantified using liquid chromatography tandem mass spectrometry. Plasma proteoglycans (syndecan-1) were measured through an immunoassay. RESULTS Among the 39 mechanically ventilated children (29 with and 10 without sepsis-associated PARDS), sepsis-associated PARDS patients demonstrated higher levels of heparan sulfate (median 639 ng/mL [interquartile range, IQR 421-902] vs 311 [IQR 228-461]) and syndecan-1 (median 146 ng/mL [IQR 32-315] vs 8 [IQR 8-50]), both p = 0.01. Heparan sulfate subtype analysis demonstrated greater proportions of N-sulfated disaccharide levels among children with sepsis-associated PARDS (p = 0.01). Increasing N-sulfated disaccharide levels by quartile were associated with severe PARDS (n = 9/29) with the highest quartile including >60% of the severe PARDS patients (test for trend, p = 0.04). Higher total heparan sulfate and N-sulfated disaccharide levels were independently associated with fewer 28-day ventilator-free days in children with sepsis-associated PARDS (all p < 0.05). CONCLUSIONS Children with sepsis-associated PARDS exhibited higher plasma levels of heparan sulfate disaccharides and syndecan-1, suggesting that EGCX degradation biomarkers may provide insights into endothelial dysfunction and PARDS pathobiology.
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Affiliation(s)
- Colin J. Sallee
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, David Geffen School of Medicine at University of California Los Angeles and Mattel Children's Hospital, Los Angeles, CA, USA
| | - Joseph A. Hippensteel
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kristen R. Miller
- Department of Pediatrics, Section of Pediatric Critical Care, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Kaori Oshima
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
| | - Andrew T. Pham
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Robert P. Richter
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - John Belperio
- Department of Medicine, Division of Pulmonary Critical Care and Sleep Medicine, David Geffen School of Medicine at University of California Los Angeles and Ronald Reagan Medical Center, Los Angeles, CA, USA
| | - Yamila L. Sierra
- Department of Pediatrics, Section of Pediatric Critical Care, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Andreas Schwingshackl
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, David Geffen School of Medicine at University of California Los Angeles and Mattel Children's Hospital, Los Angeles, CA, USA
| | - Peter M. Mourani
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA
| | - Eric P. Schmidt
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
| | - Anil Sapru
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, David Geffen School of Medicine at University of California Los Angeles and Mattel Children's Hospital, Los Angeles, CA, USA
| | - Aline B. Maddux
- Department of Pediatrics, Section of Pediatric Critical Care, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
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29
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Manchanda V, Muralidharan J, Nischal N, Aggarwal K, Gupta S, Gupta N, Velayudhan A, Kaur H, Brijwal M, Chhabra M, Vishwanathan R, Dhodapkar R, Mahajan SK, Deol S, Sekhar JC, Mitra S, Saxena S, Kumar J, Garg A, Lodha R, Ravi V, Soneja M, Verghese VP, Rodrigues C. Approach towards surveillance-based diagnosis of acute respiratory illness in India: Expert recommendations. Indian J Med Microbiol 2024; 48:100548. [PMID: 38403268 DOI: 10.1016/j.ijmmb.2024.100548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/15/2024] [Accepted: 02/19/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND Emerging infectious diseases, often zoonotic, demand a collaborative "One-Health" surveillance approach due to human activities. The need for standardized diagnostic and surveillance algorithms is emphasized to address the difficulty in clinical differentiation and curb antimicrobial resistance. OBJECTIVE The present recommendations are comprehensive diagnostic and surveillance algorithm for ARIs, developed by the Indian Council of Medical Research (ICMR), which aims to enhance early detection and treatment with improved surveillance. This algorithm shall be serving as a blueprint for respiratory infections landscape in the country and early detection of surge of respiratory infections in the country. CONTENT The ICMR has risen up to the threat of emerging and re-emerging infections. Here, we seek to recommend a structured approach for diagnosing respiratory illnesses. The recommendations emphasize the significance of prioritizing respiratory pathogens based on factors such as the frequency of occurrence (seasonal or geographical), disease severity, ease of diagnosis and public health importance. The proposed surveillance-based diagnostic algorithm for ARI relies on a combination of gold-standard conventional methods, innovative serological and molecular techniques, as well as radiological approaches, which collectively contribute to the detection of various causative agents. The diagnostic part of the integrated algorithm can be dealt at the local microbiology laboratory of the healthcare facility with the few positive and negative specimens shipped to linked viral disease research laboratories (VRDLs) and other ICMR designated laboratories for genome characterisation, cluster identification and identification of novel agents.
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Affiliation(s)
- Vikas Manchanda
- Department of Microbiology, Maulana Azad Medical College, Delhi, India.
| | - Jayshree Muralidharan
- Department of Pediatric Medicine (Advanced Pediatric Centre), PGIMER, Chandigarh, India.
| | - Neeraj Nischal
- Department of Medicine, All India Institute of Medical Sciences (AIIMS), Delhi, India
| | - Kshitij Aggarwal
- Department of Pulmonary and Critical Care Medicine, Institute of Heart and Lung Diseases, Bahadurgarh, Haryana, India
| | - Swati Gupta
- Department of Radiodiagnosis, Maulana Azad Medical College, Delhi, India
| | - Nivedita Gupta
- Division of Epidemiology & Communicable Diseases, ICMR Headquarters, New Delhi, India
| | - Anoop Velayudhan
- Division of Epidemiology & Communicable Diseases, ICMR Headquarters, New Delhi, India
| | - Harmanmeet Kaur
- Division of Epidemiology & Communicable Diseases, ICMR Headquarters, New Delhi, India
| | - Megha Brijwal
- Department of Microbiology, All India Institute of Medical Sciences (AIIMS), Delhi, India
| | - Mala Chhabra
- Department of Microbiology, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital (RML), Delhi, India
| | | | | | - Sanjay K Mahajan
- Department of Medicine, Indira Gandhi Medical College & Hospital (IGMC), Shimla, India
| | - Saumya Deol
- Division of Epidemiology & Communicable Diseases, ICMR Headquarters, New Delhi, India
| | | | - Srestha Mitra
- Department of Microbiology, Maulana Azad Medical College, Delhi, India
| | - Sonal Saxena
- Department of Microbiology, Maulana Azad Medical College, Delhi, India
| | - Jyoti Kumar
- Department of Radiodiagnosis, Maulana Azad Medical College, Delhi, India
| | - Anju Garg
- Department of Radiodiagnosis, Maulana Azad Medical College, Delhi, India
| | - Rakesh Lodha
- Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Delhi, India
| | - V Ravi
- Department of Neurovirology, NIMHANS, Bengaluru, India
| | - Manish Soneja
- Department of Medicine, All India Institute of Medical Sciences (AIIMS), Delhi, India
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Piastra M, Picconi E, Genovese O, Ferrari V, Morena TC, Valentini P, De Pascale G, Antonelli M, Conti G. Complicated Falciparum Malarial ARDS Requiring Noninvasive Support. Pediatr Infect Dis J 2024; 43:e96-e99. [PMID: 38381957 DOI: 10.1097/inf.0000000000004189] [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: 02/23/2024]
Abstract
Severe plasmodium falciparum infection can induce respiratory distress and clinical ARDS in children, requiring intensive care admission and respiratory support. We present 3 cases of imported malarial acute respiratory distress syndrome requiring noninvasive ventilation in the pediatric intensive care unit, in the absence of any cerebral involvement. Radiological features and their relationship with severe hematological complications are also illustrated.
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Affiliation(s)
- Marco Piastra
- From the Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
- Institute of Anesthesia and Intensive Care, Catholic University of the Sacred Heart, Rome, Italy
| | - Enzo Picconi
- From the Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Orazio Genovese
- From the Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Vittoria Ferrari
- Institute of Anesthesia and Intensive Care, Catholic University of the Sacred Heart, Rome, Italy
| | - Tony Christian Morena
- From the Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Piero Valentini
- Pediatric Infectious Diseases, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Gennaro De Pascale
- Institute of Anesthesia and Intensive Care, Catholic University of the Sacred Heart, Rome, Italy
| | - Massimo Antonelli
- Institute of Anesthesia and Intensive Care, Catholic University of the Sacred Heart, Rome, Italy
| | - Giorgio Conti
- From the Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
- Institute of Anesthesia and Intensive Care, Catholic University of the Sacred Heart, Rome, Italy
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31
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Executive Summary of the Second International Guidelines for the Diagnosis and Management of Pediatric Acute Respiratory Distress Syndrome (PALICC-2): Erratum. Pediatr Crit Care Med 2024; 25:e175. [PMID: 38451808 DOI: 10.1097/pcc.0000000000003473] [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: 03/09/2024]
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Dundar MA, Kendirli T, Yildizdas D. About the Second International Guidelines for the Diagnosis and Management of Pediatric Acute Respiratory Distress Syndrome. Pediatr Crit Care Med 2024; 25:e168-e169. [PMID: 38451803 DOI: 10.1097/pcc.0000000000003378] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Affiliation(s)
- Mehmet Akif Dundar
- Division of Pediatric Critical Care Medicine, Health Sciences University, Kayseri Medical Faculty, Kayseri City Training and Research Hospital, Kayseri, Turkey
| | - Tanil Kendirli
- Division of Pediatric Critical Care Medicine, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Dincer Yildizdas
- Department of Pediatric Intensive Care, Çukurova University Faculty of Medicine, Adana, Turkey
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33
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Daniels D, Conners GP. Treatment of Acute COVID-19 and COVID-19 Exposures in Children and Adolescents. Pediatr Emerg Care 2024; 40:223-230. [PMID: 38416652 DOI: 10.1097/pec.0000000000003143] [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: 03/01/2024]
Abstract
ABSTRACT The landscape of acute COVID-19 therapeutics has dramatically evolved since the onset of the pandemic. The treatment of acute COVID-19 in children and adolescents requires knowledge of risk factors and clinical features to appropriately select antiviral and immunomodulatory therapies. This review article provides updated guidance for emergency physicians in the treatment of acute COVID-19 in children and adolescents.
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Affiliation(s)
- Danielle Daniels
- From the Assistant Professor of Pediatrics, Division of Pediatric Infectious Diseases
| | - Gregory P Conners
- Stanley A. August Professor and Chair of Pediatrics, Executive Director, Upstate Golisano Children's Hospital, SUNY Upstate Medical University, Syracuse, NY
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Su J, Tie X, Chen Y, Zou T, Yin W. Successful application of airway pressure release ventilation in a child with severe acute respiratory distress syndrome induced by trauma: a case report. BMC Pulm Med 2024; 24:79. [PMID: 38347503 PMCID: PMC10863202 DOI: 10.1186/s12890-024-02894-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 02/02/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Trauma has been identified as one of the risk factors for acute respiratory distress syndrome. Respiratory support can be further complicated by comorbidities of trauma such as primary or secondary lung injury. Conventional ventilation strategies may not be suitable for all trauma-related acute respiratory distress syndrome. Airway pressure release ventilation has emerged as a potential rescue method for patients with acute respiratory distress syndrome and hypoxemia refractory to conventional mechanical ventilation. However, there is a lack of research on the use of airway pressure release ventilation in children with trauma-related acute respiratory distress syndrome. We report a case of airway pressure release ventilation applied to a child with falling injury, severe acute respiratory distress syndrome, hemorrhagic shock, and bilateral hemopneumothorax. We hope this case report presents a potential option for trauma-related acute respiratory distress syndrome and serves as a basis for future research. CASE PRESENTATION A 15-year-old female with falling injury who developed severe acute respiratory distress syndrome, hemorrhagic shock, and bilateral hemopneumothorax was admitted to the surgical intensive care unit. She presented refractory hypoxemia despite the treatment of conventional ventilation with deep analgesia, sedation, and muscular relaxation. Lung recruitment was ineffective and prone positioning was contraindicated. Her oxygenation significantly improved after the use of airway pressure release ventilation. She was eventually extubated after 12 days of admission and discharged after 42 days of hospitalization. CONCLUSION Airway pressure release ventilation may be considered early in the management of trauma patients with severe acute respiratory distress syndrome when prone position ventilation cannot be performed and refractory hypoxemia persists despite conventional ventilation and lung recruitment maneuvers.
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Affiliation(s)
- Jing Su
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xin Tie
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yao Chen
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Tongjuan Zou
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Wanhong Yin
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, China.
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35
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Huang E, Albrecht L, O’Hearn K, Nicolas N, Armstrong J, Weinberg M, Menon K. Reporting of social determinants of health in randomized controlled trials conducted in the pediatric intensive care unit. Front Pediatr 2024; 12:1329648. [PMID: 38361997 PMCID: PMC10867174 DOI: 10.3389/fped.2024.1329648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 01/19/2024] [Indexed: 02/17/2024] Open
Abstract
Introduction The influence of social determinants of health (SDOH) on access to care and outcomes for critically ill children remains an understudied area with a paucity of high-quality data. Recent publications have highlighted the importance of incorporating SDOH considerations into research but the frequency with which this occurs in pediatric intensive care unit (PICU) research is unclear. Our objective was to determine the frequency and categories of SDOH variables reported and how these variables were defined in published PICU randomized controlled trials (RCTs). Methods We searched Medline, Embase, Lilacs, and Central from inception to Dec 2022. Inclusion criteria were randomized controlled trials of any intervention on children or their families in a PICU. Data related to study demographics and nine WHO SDOH categories were extracted, and descriptive statistics and qualitative data generated. Results 586 unique RCTs were included. Studies had a median sample size of 60 patients (IQR 40-106) with 73.0% of studies including ≤100 patients and 41.1% including ≤50 patients. A total of 181 (181/586, 30.9%) studies reported ≥1 SDOH variable of which 163 (163/586, 27.8%) reported them by randomization group. The most frequently reported categories were food insecurity (100/586, 17.1%) and social inclusion and non-discrimination (73/586, 12.5%). Twenty-five of 57 studies (43.9%) investigating feeding or nutrition and 11 of 82 (13.4%) assessing mechanical ventilation reported baseline nutritional assessments. Forty-one studies investigated interventions in children with asthma or bronchiolitis of which six reported on smoking in the home (6/41, 14.6%). Discussion Reporting of relevant SDOH variables occurs infrequently in PICU RCTs. In addition, when available, categorizations and definitions of SDOH vary considerably between studies. Standardization of SDOH variable collection along with consistent minimal reporting requirements for PICU RCT publications is needed.
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Affiliation(s)
- Emma Huang
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Lisa Albrecht
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Katie O’Hearn
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Naisha Nicolas
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Jennifer Armstrong
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Maya Weinberg
- Faculty of Science, University of Ottawa, Ottawa, ON, Canada
| | - Kusum Menon
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
- Department of Pediatrics, Children’s Hospital of Eastern Ontario and University of Ottawa, Ottawa, ON, Canada
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Arias AV, Lintner-Rivera M, Shafi NI, Abbas Q, Abdelhafeez AH, Ali M, Ammar H, Anwar AI, Adabie Appiah J, Attebery JE, Diaz Villalobos WE, Ferreira D, González-Dambrauskas S, Irfan Habib M, Lee JH, Kissoon N, Tekleab AM, Molyneux EM, Morrow BM, Nadkarni VM, Rivera J, Silvers R, Steere M, Tatay D, Bhutta AT, Kortz TB, Agulnik A. A research definition and framework for acute paediatric critical illness across resource-variable settings: a modified Delphi consensus. Lancet Glob Health 2024; 12:e331-e340. [PMID: 38190831 PMCID: PMC11089938 DOI: 10.1016/s2214-109x(23)00537-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 01/10/2024]
Abstract
The true global burden of paediatric critical illness remains unknown. Studies on children with life-threatening conditions are hindered by the absence of a common definition for acute paediatric critical illness (DEFCRIT) that outlines components and attributes of critical illness and does not depend on local capacity to provide critical care. We present an evidence-informed consensus definition and framework for acute paediatric critical illness. DEFCRIT was developed following a scoping review of 29 studies and key concepts identified by an interdisciplinary, international core expert panel (n=24). A modified Delphi process was then done with a panel of multidisciplinary health-care global experts (n=109) until consensus was reached on eight essential attributes and 28 statements as the basis of DEFCRIT. Consensus was reached in two Delphi rounds with an expert retention rate of 89%. The final consensus definition for acute paediatric critical illness is: an infant, child, or adolescent with an illness, injury, or post-operative state that increases the risk for or results in acute physiological instability (abnormal physiological parameters or vital organ dysfunction or failure) or a clinical support requirement (such as frequent or continuous monitoring or time-sensitive interventions) to prevent further deterioration or death. The proposed definition and framework provide the conceptual clarity needed for a unified approach for global research across resource-variable settings. Future work will centre on validating DEFCRIT and determining high priority measures and guidelines for data collection and analysis that will promote its use in research.
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Affiliation(s)
- Anita V Arias
- Division of Critical Care and Pulmonary Medicine, Department of Pediatrics, St Jude Children's Research Hospital, Memphis, TN, USA.
| | - Michael Lintner-Rivera
- Division of Pediatric Critical Care, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nadeem I Shafi
- Division of Pediatric Critical Care, University of Tennessee Health Science Center and Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Qalab Abbas
- Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Abdelhafeez H Abdelhafeez
- Department of Surgery, St Jude Children's Research Hospital Memphis, TN, USA; Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Muhammad Ali
- Department of Pediatric Oncology, Pakistan Institute of Medical Sciences, Islamabad, Pakistan
| | - Halaashuor Ammar
- Department of Paediatrics, School of Medicine, University of Benghazi, Children's Hospital of Benghazi, Benghazi, Libya
| | - Ali I Anwar
- Lincoln Memorial University-DeBusk College of Osteopathic Medicine, Knoxville, TN, USA
| | - John Adabie Appiah
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Jonah E Attebery
- Division of Critical Care, Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | | | | | - Sebastián González-Dambrauskas
- Departamento de Pediatría y Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell, Montevideo, Uruguay; Facultad de Medicina, Universidad de la República, Montevideo, Uruguay; Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
| | | | - Jan Hau Lee
- Children's Intensive Care, KK Women's and Children's Hospital, Singapore; Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; Division of Critical Care, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Atnafu M Tekleab
- Department of Pediatrics and Child Health, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | | | - Brenda M Morrow
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia. Philadelphia, PA, USA; University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jocelyn Rivera
- Pediatric Emergency Department, Hospital Infantil Teletón de Oncología, Querétaro, México
| | - Rebecca Silvers
- Institute for Global Health Sciences and the University of California San Francisco, San Francisco, CA, USA; UCSF School of Nursing, San Francisco, CA, USA; Division of Critical Care, UCSF Benioff Children's Hospitals, San Francisco, CA, USA
| | - Mardi Steere
- Royal Flying Doctor Service (South Australia/Northern Territory), SA, Australia; Department of Paediatric Emergency Medicine, Women's and Children's Hospital, North Adelaide, SA, Australia
| | - Daniel Tatay
- Hospital de Niños de la Santísima Trinidad, Córdoba, Argentina
| | - Adnan T Bhutta
- Division of Pediatric Critical Care, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Teresa B Kortz
- Institute for Global Health Sciences and the University of California San Francisco, San Francisco, CA, USA; Division of Critical Care Medicine, Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Asya Agulnik
- Division of Critical Care and Pulmonary Medicine, Department of Pediatrics, St Jude Children's Research Hospital, Memphis, TN, USA; Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
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Fernandez-Sarmiento J, Perez MC, Bustos JD, Acevedo L, Sarta-Mantilla M, Guijarro J, Santacruz C, Pardo DF, Castro D, Rosero YV, Mulett H. Association between mechanical ventilation parameters and mortality in children with respiratory failure on ECMO: a systematic review and meta-analysis. Front Pediatr 2024; 12:1302049. [PMID: 38292212 PMCID: PMC10824827 DOI: 10.3389/fped.2024.1302049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/04/2024] [Indexed: 02/01/2024] Open
Abstract
Background In refractory respiratory failure (RF), extracorporeal membrane oxygenation (ECMO) is a salvage therapy that seeks to reduce lung injury induced by mechanical ventilation. The parameters of optimal mechanical ventilation in children during ECMO are not known. Pulmonary ventilatory management during this therapy may impact mortality. The objective of this study was to evaluate the association between ventilatory parameters in children during ECMO therapy and in-hospital mortality. Methods A systematic search of PubMed/MEDLINE, Embase, Cochrane, and Google Scholar from January 2013 until May 2022 (PROSPERO 450744), including studies in children with ECMO-supported RF assessing mechanical ventilation parameters, was conducted. Risk of bias was assessed using the Newcastle-Ottawa scale; heterogeneity, with absence <25% and high >75%, was assessed using I2. Sensitivity and subgroup analyses using the Mantel-Haenszel random-effects model were performed to explore the impact of methodological quality on effect size. Results Six studies were included. The median age was 3.4 years (IQR: 3.2-4.2). Survival in the 28-day studies was 69%. Mechanical ventilation parameters associated with higher mortality were a very low tidal volume ventilation (<4 ml/kg; OR: 4.70; 95% CI: 2.91-7.59; p < 0.01; I2: 38%), high plateau pressure (mean Dif: -0.70 95% CI: -0.18, -0.22; p < 0.01), and high driving pressure (mean Dif: -0.96 95% CI: -1.83, -0.09: p = 0.03). The inspired fraction of oxygen (p = 0.09) and end-expiratory pressure (p = 0.69) were not associated with higher mortality. Patients who survived had less multiple organ failure (p < 0.01). Conclusion The mechanical ventilation variables associated with higher mortality in children with ECMO-supported respiratory failure are high plateau pressures, high driving pressure and very low tidal volume ventilation. No association between mortality and other parameters of the mechanical ventilator, such as the inspired fraction of oxygen or end-expiratory pressure, was found. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023450744, PROSPERO 2023 (CRD42023450744).
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Affiliation(s)
- Jaime Fernandez-Sarmiento
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Maria Camila Perez
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Juan David Bustos
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Lorena Acevedo
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Mauricio Sarta-Mantilla
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Jennifer Guijarro
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Carlos Santacruz
- Department of Anesthesia and Cardiovascular Surgery, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Daniel Felipe Pardo
- Department of Anesthesia and Cardiovascular Surgery, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Daniel Castro
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Yinna Villa Rosero
- Department of Critical Care Medicine and Pediatrics, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Hernando Mulett
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
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38
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Di Nardo M. What's new in neonatal and pediatric extracorporeal membrane oxygenation in 2022-2023? Insights from the EuroELSO congress 2023. Perfusion 2024; 39:227-231. [PMID: 37566102 DOI: 10.1177/02676591231196112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Affiliation(s)
- Matteo Di Nardo
- Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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39
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Tasker RC. 2023 in Review. Pediatr Crit Care Med 2023; 24:979-982. [PMID: 38054999 DOI: 10.1097/pcc.0000000000003395] [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: 12/07/2023]
Affiliation(s)
- Robert C Tasker
- orcid.org/0000-0003-3647-8113
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Selwyn College, Cambridge University, Cambridge, United Kingdom
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40
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Morrow BM, Lozano Ray E, McCulloch M, Salie S, Salloo A, Appel IN, Du Plooy E, Cawood S, Moshesh P, Keeling KH, Solomon LJ, Hlophe S, Demopoulos D, Parker N, Khan AB, Naidoo KD, Argent AC. Pediatric Acute Respiratory Distress Syndrome in South African PICUs: A Multisite Point-Prevalence Study. Pediatr Crit Care Med 2023; 24:1063-1071. [PMID: 37523579 DOI: 10.1097/pcc.0000000000003330] [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: 08/02/2023]
Abstract
OBJECTIVES To describe the prevalence of pediatric acute respiratory distress syndrome (pARDS) and the characteristics of children with pARDS in South African PICUs. DESIGN Observational multicenter, cross-sectional point-prevalence study. SETTING Eight PICUs in four South African provinces. PATIENTS All children beyond the neonatal period and under 18 years of age admitted to participating PICUs. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Clinical and demographic data were prospectively collected on a single day of each month, from February to July 2022, using a centralized database. Cases with or at risk of pARDS were identified using the 2015 Pediatric Acute Lung Injury Consensus Conference criteria. Prevalence was calculated as the number of children meeting pARDS criteria/the total number of children admitted to PICU at the same time points. Three hundred ten patients were present in the PICU on study days: 166 (53.5%) male, median (interquartile range [IQR]) age 9.8 (3.1-32.9) months, and 195 (62.9%) invasively mechanically ventilated. Seventy-one (22.9%) patients were classified as being "at risk" of pARDS and 95 patients (prevalence 30.6%; 95% CI, 24.7-37.5%) fulfilled pARDS case criteria, with severity classified as mild (58.2%), moderate (25.3%), and severe (17.6%). Median (IQR) admission Pediatric Index of Mortality 3 risk of mortality in patients with and without pARDS was 5.6 (3.4-12.1) % versus 3.9 (1.0-8.2) % ( p = 0.002). Diagnostic categories differed between pARDS and non-pARDS groups ( p = 0.002), with no difference in age, sex, or presence of comorbidities. On multivariable logistic regression, increasing admission risk of mortality (adjusted odds ratio [aOR] 1.02; 95% CI, 1.00-1.04; p = 0.04) and being admitted with a respiratory condition (aOR 2.64; 95% CI, 1.27-5.48; p = 0.01) were independently associated with an increased likelihood of having pARDS. CONCLUSIONS The 30.6% prevalence of pARDS in South Africa is substantially higher than reports from other sociogeographical regions, highlighting the need for further research in this setting.
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Affiliation(s)
- Brenda M Morrow
- Department of Pediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Division of Pediatric Intensive Care, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Eleonora Lozano Ray
- Department of Pediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Division of Pediatric Intensive Care, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Mignon McCulloch
- Department of Pediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Division of Pediatric Intensive Care, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Shamiel Salie
- Department of Pediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Division of Pediatric Intensive Care, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Asma Salloo
- Department of Pediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Division of Pediatric Intensive Care, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Ilse N Appel
- Department of Pediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Division of Pediatric Intensive Care, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Elri Du Plooy
- Department of Pediatrics, Tygerberg Children's Hospital, Stellenbosch University, Cape Town, South Africa
| | - Shannon Cawood
- Pediatric Intensive Care Unit, Nelson Mandela Children's Hospital, Johannesburg, South Africa
| | - Porai Moshesh
- Pediatric Intensive Care Unit, Nelson Mandela Children's Hospital, Johannesburg, South Africa
| | - Kathryn H Keeling
- Pediatric Intensive Care Unit, Nelson Mandela Children's Hospital, Johannesburg, South Africa
| | - Lincoln J Solomon
- Department of Pediatrics and Child Health, University of the Free State, Bloemfontein, South Africa
- Department of Paediatrics, Universitas Academic and Pelonomi Tertiary Hospitals, Bloemfontein, South Africa
| | - Sbekezelo Hlophe
- Department of Paediatrics, Greys Hospital, Pietermaritzburg, South Africa
| | - Despina Demopoulos
- Department of Paediatrics, WITS Donald Gordon Medical Centre, Johannesburg, South Africa
| | - Noor Parker
- Department of Pediatrics, Tygerberg Children's Hospital, Stellenbosch University, Cape Town, South Africa
| | - Ayesha Bibi Khan
- Department of Paediatrics, Chris Hani Baragwanath Hospital, Johannesburg, South Africa
- Division of Critical Care, University of the Witwatersrand, Johannesburg, South Africa
| | - Kuban D Naidoo
- Department of Paediatrics, Chris Hani Baragwanath Hospital, Johannesburg, South Africa
- Division of Critical Care, University of the Witwatersrand, Johannesburg, South Africa
| | - Andrew C Argent
- Department of Pediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Division of Pediatric Intensive Care, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
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Straube TL, Rotta AT. Sedation, Relaxation, and a Tube in the Nose: Which Are Associated With Longer Mechanical Ventilation Woes? Early Management Strategies and Outcomes in Critical Bronchiolitis. Pediatr Crit Care Med 2023; 24:1086-1089. [PMID: 38055002 DOI: 10.1097/pcc.0000000000003361] [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: 12/07/2023]
Affiliation(s)
- Tobias L Straube
- Both authors: Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC
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Leland SB, Staffa SJ, Newhams MM, Khemani RG, Marshall JC, Young CC, Maddux AB, Hall MW, Weiss SL, Schwarz AJ, Coates BM, Sanders RC, Kong M, Thomas NJ, Nofziger RA, Cullimore ML, Halasa NB, Loftis LL, Cvijanovich NZ, Schuster JE, Flori H, Gertz SJ, Hume JR, Olson SM, Patel MM, Zurakowski D, Randolph AG. The Modified Clinical Progression Scale for Pediatric Patients: Evaluation as a Severity Metric and Outcome Measure in Severe Acute Viral Respiratory Illness. Pediatr Crit Care Med 2023; 24:998-1009. [PMID: 37539964 PMCID: PMC10688559 DOI: 10.1097/pcc.0000000000003331] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
OBJECTIVES To develop, evaluate, and explore the use of a pediatric ordinal score as a potential clinical trial outcome metric in children hospitalized with acute hypoxic respiratory failure caused by viral respiratory infections. DESIGN We modified the World Health Organization Clinical Progression Scale for pediatric patients (CPS-Ped) and assigned CPS-Ped at admission, days 2-4, 7, and 14. We identified predictors of clinical improvement (day 14 CPS-Ped ≤ 2 or a three-point decrease) using competing risks regression and compared clinical improvement to hospital length of stay (LOS) and ventilator-free days. We estimated sample sizes (80% power) to detect a 15% clinical improvement. SETTING North American pediatric hospitals. PATIENTS Three cohorts of pediatric patients with acute hypoxic respiratory failure receiving intensive care: two influenza (pediatric intensive care influenza [PICFLU], n = 263, 31 sites; PICFLU vaccine effectiveness [PICFLU-VE], n = 143, 17 sites) and one COVID-19 ( n = 237, 47 sites). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Invasive mechanical ventilation rates were 71.4%, 32.9%, and 37.1% for PICFLU, PICFLU-VE, and COVID-19 with less than 5% mortality for all three cohorts. Maximum CPS-Ped (0 = home at respiratory baseline to 8 = death) was positively associated with hospital LOS ( p < 0.001, all cohorts). Across the three cohorts, many patients' CPS-Ped worsened after admission (39%, 18%, and 49%), with some patients progressing to invasive mechanical ventilation or death (19%, 11%, and 17%). Despite this, greater than 76% of patients across cohorts clinically improved by day 14. Estimated sample sizes per group using CPS-Ped to detect a percentage increase in clinical improvement were feasible (influenza 15%, n = 142; 10%, n = 225; COVID-19, 15% n = 208) compared with mortality ( n > 21,000, all), and ventilator-free days (influenza 15%, n = 167). CONCLUSIONS The CPS-Ped can be used to describe the time course of illness and threshold for clinical improvement in hospitalized children and adolescents with acute respiratory failure from viral infections. This outcome measure could feasibly be used in clinical trials to evaluate in-hospital recovery.
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Affiliation(s)
- Shannon B Leland
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Margaret M Newhams
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, University of Southern California, Keck School of Medicine, Los Angeles, CA
| | - John C Marshall
- Department of Surgery, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Cameron C Young
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Aline B Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Scott L Weiss
- Division of Critical Care, Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Adam J Schwarz
- Division of Critical Care Medicine, Children's Hospital Orange County (CHOC), Orange, CA
| | - Bria M Coates
- Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Ronald C Sanders
- Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, AR
| | - Michele Kong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Neal J Thomas
- Department of Pediatrics, Penn State Hershey Children's Hospital, Penn State University College of Medicine, Hershey, PA
| | - Ryan A Nofziger
- Division of Critical Care Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, OH
| | - Melissa L Cullimore
- Division of Pediatric Critical Care, Department of Pediatrics, Children's Hospital and Medical Center, Omaha, NE
| | - Natasha B Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Laura L Loftis
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Houston, TX
| | - Natalie Z Cvijanovich
- Division of Critical Care Medicine, UCSF Benioff Children's Hospital Oakland, Oakland, CA
| | - Jennifer E Schuster
- Division of Pediatric Infectious Disease, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO
| | - Heidi Flori
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Mott Children's Hospital and University of Michigan, Ann Arbor, MI
| | - Shira J Gertz
- Division of Pediatric Critical Care, Department of Pediatrics, Cooperman Barnabas Medical Center, Livingston, NJ
| | - Janet R Hume
- Division of Pediatric Critical Care, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Samantha M Olson
- Influenza Division and CDC COVID-19 Response Team, Centers for Disease Control of Prevention, National Center for Immunization and Respiratory Diseases (NCIRD), Atlanta, GA
| | - Manish M Patel
- Influenza Division and CDC COVID-19 Response Team, Centers for Disease Control of Prevention, National Center for Immunization and Respiratory Diseases (NCIRD), Atlanta, GA
| | - David Zurakowski
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
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Furlong-Dillard JM, Nguyen A, Facciolo MD, Feygin YB, Napolitano N, Emeriaud G, Berkenbosch JW, Owen EB. Associations With Severe Desaturation Events Among Children Receiving Noninvasive Respiratory Support at Time of Intubation. Respir Care 2023; 68:1646-1656. [PMID: 37553217 PMCID: PMC10676262 DOI: 10.4187/respcare.10765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
BACKGROUND Endotracheal intubation is a common procedure associated with adverse events, including severe desaturation. Many patients receive noninvasive respiratory support to reduce the need for intubation. There are minimal data about the association between noninvasive respiratory support and the risk of a severe desaturation event during intubation. We aim to differentiate patients based on the level of noninvasive respiratory support, analyze the severe desaturation event by groups, and identify modifiable risk factors. METHODS Oral intubations, excluding tube exchanges or re-intubation after unplanned extubation, from October 2018 through July 2020, at the study site were reviewed. A severe desaturation event was defined as [Formula: see text] < 70% or a >15% decrease from baseline in cyanotic heart disease. We analyzed outcomes by 4 groups: room air/nasal cannula (≤0.5 L/kg/min), high-flow nasal cannula (HFNC) (0.5-2 L/kg/min), high HFNC (≥2 L/kg/min), and noninvasive ventilation (NIV). RESULTS Of 243 subjects who were intubated, 31% were receiving room air/nasal cannula, 25% were receiving HFNC, 18% were receiving high HFNC, and 26% were receiving NIV. Twelve percent of all the subjects had a severe desaturation event. In a univariate analysis, the incidence of a severe desaturation event was similar among all levels of respiratory support (P = .14). A severe desaturation event was more likely in those subjects who were receiving [Formula: see text] ≥ 0.6 at the time of the decision to intubate (19.6%) versus [Formula: see text] < 0.6 (8.1%) (P = .02). The duration of noninvasive respiratory support was longer (5 vs 1 h; P = .02) among those with a severe desaturation event. In a regression analysis, when adjusting for ≥2 intubation attempts pre-intubation, NIV use was independently associated with increased odds of severe desaturation events (odds ratio 3.14, CI 1.08-10.5). CONCLUSIONS Results of our study suggest that [Formula: see text] > 0.60, the duration of noninvasive respiratory support, and exposure to NIV before an intubation are risk factors of severe desaturation events during intubation.
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Affiliation(s)
- Jamie M Furlong-Dillard
- Division of Pediatric Critical Care, Department of Pediatrics, Norton Children's Hospital, University of Louisville School of Medicine, Louisville, Kentucky.
| | - Anh Nguyen
- Division of Pediatric Critical Care, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Michael D Facciolo
- Division of Pediatric Critical Care, Department of Pediatrics, Norton Children's Hospital, University of Louisville School of Medicine, Louisville, Kentucky
| | - Yana B Feygin
- Norton Children's Research Institute affiliated with the University of Louisville School of Medicine, Louisville, Kentucky
| | - Natalie Napolitano
- Respiratory Care Department, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Guillaume Emeriaud
- Division des Soins Intensifs Pédiatriques, Département de Pédiatrie, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - John W Berkenbosch
- Division of Pediatric Critical Care, Department of Pediatrics, Norton Children's Hospital, University of Louisville School of Medicine, Louisville, Kentucky
| | - Erin B Owen
- Division of Pediatric Critical Care, Department of Pediatrics, Norton Children's Hospital, University of Louisville School of Medicine, Louisville, Kentucky
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Woods-Hill CZ, Wolfe H, Malone S, Steffen KM, Agulnik A, Flaherty BF, Barbaro RP, Dewan M, Kudchadkar S. Implementation Science Research in Pediatric Critical Care Medicine. Pediatr Crit Care Med 2023; 24:943-951. [PMID: 37916878 PMCID: PMC10624111 DOI: 10.1097/pcc.0000000000003335] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
OBJECTIVES Delay or failure to consistently adopt evidence-based or consensus-based best practices into routine clinical care is common, including for patients in the PICU. PICU patients can fail to receive potentially beneficial diagnostic or therapeutic interventions, worsening the burden of illness and injury during critical illness. Implementation science (IS) has emerged to systematically address this problem, but its use of in the PICU has been limited to date. We therefore present a conceptual and methodologic overview of IS for the pediatric intensivist. DESIGN The members of Excellence in Pediatric Implementation Science (ECLIPSE; part of the Pediatric Acute Lung Injury and Sepsis Investigators Network) represent multi-institutional expertise in the use of IS in the PICU. This narrative review reflects the collective knowledge and perspective of the ECLIPSE group about why IS can benefit PICU patients, how to distinguish IS from quality improvement (QI), and how to evaluate an IS article. RESULTS IS requires a shift in one's thinking, away from questions and outcomes that define traditional clinical or translational research, including QI. Instead, in the IS rather than the QI literature, the terminology, definitions, and language differs by specifically focusing on relative importance of generalizable knowledge, as well as aspects of study design, scale, and timeframe over which the investigations occur. CONCLUSIONS Research in pediatric critical care practice must acknowledge the limitations and potential for patient harm that may result from a failure to implement evidence-based or professionals' consensus-based practices. IS represents an innovative, pragmatic, and increasingly popular approach that our field must readily embrace in order to improve our ability to care for critically ill children.
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Affiliation(s)
- Charlotte Z Woods-Hill
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Heather Wolfe
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Sara Malone
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine
| | - Katherine M Steffen
- Stanford University Department of Pediatrics, Division of Pediatric Critical Care Medicine
| | - Asya Agulnik
- Department of Global Pediatric Medicine, Division of Critical Care, St Jude Children’s Research Hospital
| | - Brian F Flaherty
- University of Utah, Department of Pediatrics, Division of Critical Care
| | - Ryan P Barbaro
- Division of Pediatric Critical Care, University of Michigan Medical School, Ann Arbor, MI; Susan B. Miester Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI
| | - Maya Dewan
- Department of Pediatrics, University of Cincinnati College of Medicine; Cincinnati, OH; Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center; Cincinnati, OH; Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center; Cincinnati, OH
| | - Sapna Kudchadkar
- Department of Anesthesiology and Critical Care Medicine; Department of Pediatrics; Department of Physical Medicine & Rehabilitation. Johns Hopkins University School of Medicine, Baltimore, Maryland
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Cruces P, Moreno D, Reveco S, Améstica M, Araneda P, Ramirez Y, Vásquez-Hoyos P, Díaz F. Capnometry after an inspiratory breath hold, PLAT CO 2 , as a surrogate for P aCO 2 ${P}_{{\mathrm{aCO}}_{2}}$ in mild to moderate pediatric acute respiratory distress syndrome: A feasibility study. Pediatr Pulmonol 2023; 58:2899-2905. [PMID: 37594148 DOI: 10.1002/ppul.26610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 07/05/2023] [Accepted: 07/10/2023] [Indexed: 08/19/2023]
Abstract
OBJECTIVE Accurate and reliable noninvasive methods to estimate gas exchange are necessary to guide clinical decisions to avoid frequent blood samples in children with pediatric acute respiratory distress syndrome (PARDS). We aimed to investigate the correlation and agreement between end-tidalP CO 2 ${P}_{{\mathrm{CO}}_{2}}$ measured immediately after a 3-s inspiratory-hold (PLAT CO2 ) by capnometry andP aCO 2 ${P}_{{\mathrm{aCO}}_{2}}$ measured by arterial blood gases (ABG) in PARDS. DESIGN Prospective cohort study. SETTING Seven-bed Pediatric Intensive Care Unit, Hospital El Carmen de Maipú, Chile. PATIENTS Thirteen mechanically ventilated patients aged ≤15 years old undergoing neuromuscular blockade as part of management for PARDS. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS All patients were in volume-controlled ventilation mode. The regular end-tidalP CO 2 ( P ETCO 2 ) ${P}_{{\mathrm{CO}}_{2}}({P}_{{\mathrm{ETCO}}_{2}})$ (without the inspiratory hold) was registered immediately after the ABG sample. An inspiratory-hold of 3 s was performed for lung mechanics measurements, recordingP ETCO 2 ${P}_{{\mathrm{ETCO}}_{2}}$ in the breath following the inspiratory-hold. (PLAT CO2 ). End-tidal alveolar dead space fraction (AVDSf) was calculated as[ ( P aCO 2 - P ETCO 2 ) / P aCO 2 ] $[({P}_{{\mathrm{aCO}}_{2}}\mbox{--}{P}_{{\mathrm{ETCO}}_{2}})/{P}_{{\mathrm{aCO}}_{2}}]$ and its surrogate (S)AVDSf as[ ( PLAT CO 2 - P ETCO 2 ) / PLAT CO 2 ] $[{(}_{\mathrm{PLAT}}{\mathrm{CO}}_{2}\mbox{--}{P}_{{\mathrm{ETCO}}_{2}}){/}_{\mathrm{PLAT}}{\mathrm{CO}}_{2}]$ . Measurements ofP aCO 2 ${P}_{{\mathrm{aCO}}_{2}}$ were considered the gold standard. We performed concordance correlation coefficient (ρc), Spearman's correlation (rho), and Bland-Altmann's analysis (mean difference ± SD [limits of agreement, LoA]). Eleven patients were included, with a median (interquartile range) age of 5 (2-11) months. Tidal volume was 5.8 (5.7-6.3) mL/kg, PEEP 8 (6-8), driving pressure 10 (8-11), and plateau pressure 17 (17-19) cm H2 O. Forty-one paired measurements were analyzed.P aCO 2 ${P}_{{\mathrm{aCO}}_{2}}$ was higher thanP ETCO 2 ${P}_{{\mathrm{ETCO}}_{2}}$ (52 mmHg [48-54] vs. 42 mmHg [38-45], p < 0.01), and there were no significant differences with PLAT CO2 (50 mmHg [46-55], p > 0.99). The concordance correlation coefficient and Spearman's correlation betweenP aCO 2 ${P}_{{\mathrm{aCO}}_{2}}$ and PLAT CO2 were robust (ρc = 0.80 [95% confidence interval [CI]: 0.67-0.90]; and rho = 0.80, p < 0.001.), and forP ETCO 2 ${P}_{{\mathrm{ETCO}}_{2}}$ were weak and strong (ρc = 0.27 [95% CI: 0.15-0.38]; and rho = 0.63, p < 0.01). The bias between PLAT CO2 andP aCO 2 ${P}_{{\mathrm{aCO}}_{2}}$ was -0.4 ± 3.5 mmHg (LoA -7.2 to 6.4), and betweenP ETCO 2 ${P}_{{\mathrm{ETCO}}_{2}}$ andP aCO 2 ${P}_{{\mathrm{aCO}}_{2}}$ was -8.5 ± 4.1 mmHg (LoA -16.6 to -0.5). The correlation between AVDSf and (S)AVDSf was moderate (rho = 0.55, p < 0.01), and the mean difference was -0.5 ± 5.6% (LoA -11.5 to 10.5). CONCLUSION This pilot study showed the feasibility of measuring end-tidal CO2 after a 3-s end-inspiratory breath hole in pediatric patients undergoing controlled ventilation for ARDS. Encouraging preliminary results warrant further study of this technique.
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Affiliation(s)
- Pablo Cruces
- Unidad de Paciente Crítico Pediátrico, Departamento de Pediatría, Hospital El Carmen de Maipú, Santiago, Chile
- Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Colombia
| | - Diego Moreno
- Unidad de Paciente Crítico Pediátrico, Departamento de Pediatría, Hospital El Carmen de Maipú, Santiago, Chile
| | - Sonia Reveco
- Unidad de Paciente Crítico Pediátrico, Departamento de Pediatría, Hospital El Carmen de Maipú, Santiago, Chile
| | - Marjorie Améstica
- Unidad de Paciente Crítico Pediátrico, Departamento de Pediatría, Hospital El Carmen de Maipú, Santiago, Chile
| | - Patricio Araneda
- Unidad de Paciente Crítico Pediátrico, Departamento de Pediatría, Hospital El Carmen de Maipú, Santiago, Chile
| | - Yenny Ramirez
- Unidad de Paciente Crítico Pediátrico, Departamento de Pediatría, Hospital El Carmen de Maipú, Santiago, Chile
| | - Pablo Vásquez-Hoyos
- Departamento de Pediatría, Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia
- Departamento de Pediatría, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Franco Díaz
- Unidad de Paciente Crítico Pediátrico, Departamento de Pediatría, Hospital El Carmen de Maipú, Santiago, Chile
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Colombia
- Unidad de Investigación y epidemiología clínica, Escuela de Medicina, Universidad Finis Terrae, Santiago, Chile
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Rambaud J, Broman LM, Chevret S, Visconti F, Leger PL, Guner Y, Butragueño-Laiseca L, Piloquet JE, Di Nardo M. Association between pediatric intensive care mortality and mechanical ventilation settings during extracorporeal membrane oxygenation for pediatric acute respiratory distress syndrome. Eur J Pediatr 2023; 182:4487-4497. [PMID: 37491617 DOI: 10.1007/s00431-023-05119-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/11/2023] [Accepted: 07/15/2023] [Indexed: 07/27/2023]
Abstract
The main objective of this study was to describe the current mechanical ventilation (MV) settings during extracorporeal membrane oxygenation (ECMO) for pediatric acute respiratory distress syndrome (P-ARDS) in six European centers. This is a retrospective observational cohort study performed in six European centers from January 2009 to December 2019. Children > 1 month to 18 years supported with ECMO for refractory P-ARDS were included. Collected data were as follows: patients' pre-ECMO medical condition, pre-ECMO adjunctive therapies for P-ARDS, pre-ECMO and during ECMO MV settings on day (D) 1, D3, D7, and D14 of ECMO, use of adjunctive therapies during ECMO, duration of ECMO, pediatric intensive care unit length of stay, and survival. A total of 255 patients with P-ARDS were included. The multivariate analysis showed that PEEP on D1 (OR = 1.13, 95% CI [1.03-1.24], p = 0.01); D3 (OR = 1.17, 95% CI [1.06-1.29], p = 0.001); and D14 (OR = 1.21, 95% CI [1.05-1.43], p = 0.02) and DP on D7 were significantly associated with higher odds of mortality (OR = 0.82, 95% CI [0.71-0.92], p = 0.001). Moreover, DP on D1 above 15 cmH2O (OR 2.23, 95% CI (1.09-4.71), p = 0.03) and native lung FiO2 above 60% on D14 (OR 10.36, 95% CI (1.51-116.15), p = 0.03) were significantly associated with higher odds of mortality. Conclusion: MV settings during ECMO for P-ARDS varied among centers; however, use of high PEEP levels during ECMO was associated with higher odds of mortality as well as a DP above 15 cmH2O and a native lung FiO2 above 60% on D14 of ECMO. What is Known: • Invasive ventilation settings are well defined for pediatric acute respiratory distress syndrome; however, once the children required an extracorporeal respiratory support, there is no recommendation how to set the mechanical ventilator. • Impact of invasive ventilator during extracorporeal respiratory support ad only been during the first days of this support but the effects of these settings later in the assistance are not described. What is New: • It seems to be essential to early decrease FiO2 on native lung once the ECMO flow allows an efficient oxygenation. • Tight control to limit the driving pressure at 15 cmH20 during ECMO run seems to be associated with better survival rate.
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Affiliation(s)
- Jerome Rambaud
- Pediatric and Neonatal Intensive Care Unit, Armand-Trousseau Hospital, Sorbonne University, Paris, France.
| | - Lars M Broman
- ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, Sweden
| | | | - Federico Visconti
- Anaesthesia and Intensive Care, Padova University Hospital, Padua, Italy
| | - Pierre-Louis Leger
- Pediatric and Neonatal Intensive Care Unit, Armand-Trousseau Hospital, Sorbonne University, Paris, France
| | - Yigit Guner
- Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, CA, USA
| | - Laura Butragueño-Laiseca
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Jean-Eudes Piloquet
- Pediatric and Neonatal Intensive Care Unit, Nantes Universitary Hospital, Nantes, France
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Flerlage T, Fan K, Qin Y, Agulnik A, Arias AV, Cheng C, Elbahlawan L, Ghafoor S, Hurley C, McArthur J, Morrison RR, Zhou Y, Park HJ, Carcillo JA, Hines MR. Mortality Risk Factors in Pediatric Onco-Critical Care Patients and Machine Learning Derived Early Onco-Critical Care Phenotypes in a Retrospective Cohort. Crit Care Explor 2023; 5:e0976. [PMID: 37780176 PMCID: PMC10538916 DOI: 10.1097/cce.0000000000000976] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023] Open
Abstract
OBJECTIVES To use supervised and unsupervised statistical methodology to determine risk factors associated with mortality in critically ill pediatric oncology patients to identify patient phenotypes of interest for future prospective study. DESIGN This retrospective cohort study included nonsurgical pediatric critical care admissions from January 2017 to December 2018. We determined the prevalence of multiple organ failure (MOF), ICU mortality, and associated factors. Consensus k-means clustering analysis was performed using 35 bedside admission variables for early, onco-critical care phenotype development. SETTING Single critical care unit in a subspeciality pediatric hospital. INTERVENTION None. PATIENTS There were 364 critical care admissions in 324 patients with underlying malignancy, hematopoietic cell transplant, or immunodeficiency reviewed. MEASUREMENTS Prevalence of multiple organ failure, ICU mortality, determination of early onco-critical care phenotypes. MAIN RESULTS ICU mortality was 5.2% and was increased in those with MOF (18.4% MOF, 1.7% single organ failure [SOF], 0.6% no organ failure; p ≤ 0.0001). Prevalence of MOF was 23.9%. Significantly increased ICU mortality risk was associated with day 1 MOF (hazards ratio [HR] 2.27; 95% CI, 1.10-6.82; p = 0.03), MOF during ICU admission (HR 4.16; 95% CI, 1.09-15.86; p = 0.037), and with invasive mechanical ventilation requirement (IMV; HR 5.12; 95% CI, 1.31-19.94; p = 0.018). Four phenotypes were derived (PedOnc1-4). PedOnc1 and 2 represented patient groups with low mortality and SOF. PedOnc3 was enriched in patients with sepsis and MOF with mortality associated with liver and renal dysfunction. PedOnc4 had the highest frequency of ICU mortality and MOF characterized by acute respiratory failure requiring invasive mechanical ventilation at admission with neurologic dysfunction and/or severe sepsis. Notably, most of the mortality in PedOnc4 was early (i.e., within 72 hr of ICU admission). CONCLUSIONS Mortality was lower than previously reported in critically ill pediatric oncology patients and was associated with MOF and IMV. These findings were further validated and expanded by the four derived nonsynonymous computable phenotypes. Of particular interest for future prospective validation and correlative biological study was the PedOnc4 phenotype, which was composed of patients with hypoxic respiratory failure requiring IMV with sepsis and/or neurologic dysfunction at ICU admission.
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Affiliation(s)
- Tim Flerlage
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, TN
| | - Kimberly Fan
- Division of Critical Care, Department of Pediatrics, MD Anderson Cancer Center, Houston, TX
| | - Yidi Qin
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Asya Agulnik
- Department of Global Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Anita V Arias
- Division of Critical Care, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Cheng Cheng
- Division of Critical Care, Department Biostatistics, St Jude Children's Research Hospital, Memphis, TN
| | - Lama Elbahlawan
- Division of Critical Care, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Saad Ghafoor
- Division of Critical Care, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Caitlin Hurley
- Division of Critical Care, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Jennifer McArthur
- Division of Critical Care, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - R Ray Morrison
- Division of Critical Care, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Yinmei Zhou
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN
| | - H J Park
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Joseph A Carcillo
- Division of Pediatric Critical Care, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Melissa R Hines
- Division of Critical Care, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
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Tasker RC. Writing for Pediatric Critical Care Medicine: Engaging With Citations to References in the Chatbot Generative Pre-Trained Transformer Era. Pediatr Crit Care Med 2023; 24:862-868. [PMID: 38412368 DOI: 10.1097/pcc.0000000000003356] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Affiliation(s)
- Robert C Tasker
- orcid.org/0000-0003-3647-8113
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Selwyn College, Cambridge University, Cambridge, United Kingdom
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Liu L, Zhang Y, Wang Y, He Y, Ding X, Chen L, Shi Y. The perinatal period should be considered in neonatal acute respiratory distress syndrome: comparison of the Montreux definition vs. the second pediatric acute lung injury consensus conference definition. Front Pediatr 2023; 11:1216073. [PMID: 37842021 PMCID: PMC10568643 DOI: 10.3389/fped.2023.1216073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 09/19/2023] [Indexed: 10/17/2023] Open
Abstract
Background The recently developed Montreux definition for neonatal acute respiratory distress syndrome (ARDS) partially differs from the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) definition. Here, we compare the Montreux and PALICC-2 definitions regarding morbidity, mortality, and prognosis of neonatal cases of ARDS in order to evaluate which definition is more appropriate for newborns. Methods Neonates admitted to our neonatal intensive care unit between 1 January 2018 and 30 September 2019 who met the Montreux or PALICC-2 definition of neonatal ARDS were retrospectively analyzed (n = 472). One comparison was made between application of the Montreux and PALICC-2 definitions to neonates outside the perinatal period (> 7 d after birth). A second comparison was made between a diagnosis of neonatal ARDS within (≤ 7 d of birth) and outside (> 7 d after birth) the perinatal period using the Montreux definition. Results No significant differences in morbidity, mortality, severity, therapies, or prognosis were observed between neonates in the extra perinatal group according to the Montreux and PALICC-2 definitions. However, epidemiology, clinical course, and prognosis of neonatal ARDS within the perinatal period did differ from those outside the perinatal period according to the Montreux definition. Conclusion Neonates with ARDS within the perinatal period have unique triggers, epidemiology, clinical course, and prognosis, yet a similar pathobiology pattern, to neonates at other ages. Therefore, it may be essential to consider the perinatal period when defining neonatal ARDS.
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Affiliation(s)
- Liting Liu
- Department of Neonatology, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Infection and Immunity, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yihan Zhang
- Department of Neonatology, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Infection and Immunity, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yiran Wang
- Department of Neonatology, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Infection and Immunity, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yu He
- Department of Neonatology, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Infection and Immunity, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Xionghui Ding
- Department of Burn and Plastic Surgery, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Long Chen
- Department of Neonatology, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Infection and Immunity, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yuan Shi
- Department of Neonatology, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Infection and Immunity, Children's Hospital of Chongqing Medical University, Chongqing, China
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50
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Emeriaud G, Pons-Òdena M, Bhalla AK, Shein SL, Killien EY, Alapont VMI, Rowan C, Baudin F, Lin JC, Grégoire G, Napolitano N, Mayordomo-Colunga J, Diaz F, Cruces P, Medina A, Smith L, Khemani RG. Noninvasive Ventilation for Pediatric Acute Respiratory Distress Syndrome: Experience From the 2016/2017 Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Prospective Cohort Study. Pediatr Crit Care Med 2023; 24:715-726. [PMID: 37255352 PMCID: PMC10524424 DOI: 10.1097/pcc.0000000000003281] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVES The worldwide practice and impact of noninvasive ventilation (NIV) in pediatric acute respiratory distress syndrome (PARDS) is unknown. We sought to describe NIV use and associated clinical outcomes in PARDS. DESIGN Planned ancillary study to the 2016/2017 prospective Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology study. SETTING One hundred five international PICUs. PATIENTS Patients with newly diagnosed PARDS admitted during 10 study weeks. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Children were categorized by their respiratory support at PARDS diagnosis into NIV or invasive mechanical ventilation (IMV) groups. Of 708 subjects with PARDS, 160 patients (23%) received NIV at PARDS diagnosis (NIV group). NIV failure rate (defined as tracheal intubation or death) was 84 of 160 patients (53%). Higher nonrespiratory pediatric logistic organ dysfunction (PELOD-2) score, Pa o2 /F io2 was less than 100 at PARDS diagnosis, immunosuppression, and male sex were independently associated with NIV failure. NIV failure was 100% among patients with nonrespiratory PELOD-2 score greater than 2, Pa o2 /F io2 less than 100, and immunosuppression all present. Among patients with Pa o2 /F io2 greater than 100, children in the NIV group had shorter total duration of NIV and IMV, than the IMV at initial diagnosis group. We failed to identify associations between NIV use and PICU survival in a multivariable Cox regression analysis (hazard ratio 1.04 [95% CI, 0.61-1.80]) or mortality in a propensity score matched analysis ( p = 0.369). CONCLUSIONS Use of NIV at PARDS diagnosis was associated with shorter exposure to IMV in children with mild to moderate hypoxemia. Even though risk of NIV failure was high in some children, we failed to identify greater hazard of mortality in these patients.
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Affiliation(s)
- Guillaume Emeriaud
- Department of Pediatrics, Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Marti Pons-Òdena
- Inmune and Respiratory dysfunction in the child research group. Institut de Recerca Sant Joan de Déu, Santa Rosa 39-57, 08950 Esplugues de Llobregat, Spain
- Pediatric Intensive Care and Intermediate care Department, Sant Joan de Déu University Hospital, Universitat de Barcelona, Esplugues de Llobregat, Spain
| | - Anoopindar K Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, USA
| | - Steven L Shein
- Rainbow Babies and Children’s Hospital, Division of Pediatric Critical Care Medicine, Cleveland Ohio USA
| | - Elizabeth Y Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, USA
| | | | - Courtney Rowan
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN, USA
| | - Florent Baudin
- Réanimation Pédiatrique, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Lyon, France
| | - John C Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, USA
| | - Gabrielle Grégoire
- Applied Clinical Research Unit, CHU Sainte-Justine, Montreal, QC, Canada
| | - Natalie Napolitano
- Respiratory Therapy Department, Children’s Hospital of Philadelphia, USA
| | - Juan Mayordomo-Colunga
- Pediatric Intensive Care Unit. Hospital Universitario Central de Asturias, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Spain
| | - Franco Diaz
- Instituto de Ciencias e innovación en medicina (ICIM), Universidad del Desarrollo, Santiago de Chile
- Unidad de Paciente Crítico Pediátrico, Hospital El Carmen de Maipú, Santiago de Chile
| | - Pablo Cruces
- Unidad de Paciente Crítico Pediátrico, Hospital El Carmen de Maipú, Santiago de Chile
- Escuela de Medicina Veterinaria, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Alberto Medina
- Pediatric Intensive Care Unit. Hospital Universitario Central de Asturias, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Spain
| | - Lincoln Smith
- Department of Pediatrics, University of Washington, Seattle Children’s Hospital, USA
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, USA
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