Repeated bedside echocardiography in children with respiratory failure

A Review on the Impact of Bedside Echocardiography in Managing Critically Ill Children in the Pediatric Intensive Care Unit

Over the past three decades, a variety of non-invasive hemodynamic devices have been developed. However, none of the existing methods, such as transthoracic echocardiography, esophageal Doppler ultrasound, plethysmography, thoracic impedancemetry, or sublingual capnography, fully embody the ideal characteristics of reliability, reproducibility, rapid response, ease of use, comprehensive safety, affordability, and continuous monitoring capacity. Among these, echocardiography stands out as a particularly effective approach, meeting many of these criteria due to its widespread availability, relative ease of use, and critical role in detecting anatomical abnormalities and basic changes in myocardial function. It is frequently used in pediatric intensive care units to assess the structure and function of the heart muscle. The effectiveness of echocardiography in pediatric critical care is also constrained by the need for high-quality imaging and accurate interpretation. Currently, there is a notable lack of literature on the application of echocardiography in pediatric critical care. This study seeks to evaluate the existing scientific evidence regarding the effectiveness of echocardiography as a tool for monitoring hemodynamics in pediatric critical care settings.

Ultrasound cardiac output monitoring in mechanically ventilated children

AIM

To non-invasively identify the hemodynamic changes in critically ill children during the first 48 h following initiation of mechanical ventilation by the ultrasound cardiac output monitor (USCOM) method and compare the data in children with pulmonary and non-pulmonary pathology.

MATERIALS AND METHODS

This was a prospective observational study to evaluate the influence of mechanical ventilation on hemodynamic changes and to describe hemodynamic profiles of mechanically ventilated children. A total of 56 children with respiratory failure were included in the present study. Ventilated patients are divided into two groups. Group A (n=36) includes patients with pulmonary pathology. Group B (n=20) consists of patients with extra pulmonary etiology of respiratory failure. Hemodynamic parameters (cardiac index and systemic vascular resistance index) were evaluated using ultrasound cardiac output monitoring (USCOM 1A) immediately following initiation of mechanical ventilation and again at 6, 12, and 48 h. Pharmacological circulatory support (inotropes, vasopressors, levosimendan and phosphodiesterase III inhibitors) was individually and continuously modified based on real-time hemodynamic parameters and optimal fluid balance.

RESULTS

No significant differences in hemodynamic profiles were found between Group A and Group B.

CONCLUSION

The protective strategy of mechanical ventilation was not associated with significant differences in hemodynamic profiles between children ventilated for pulmonary and non-pulmonary pathologies.

CLINICAL SIGNIFICANCE

Hemodynamically unstable children ventilated for pulmonary pathology with the protective strategy of mechanical ventilation had a greater requirement for inotropic and combined inotropic and vasoactive circulatory support than children ventilated for non-pulmonary causes of respiratory failure.

Clinical impact and efficacy of bedside echocardiography on patient management in pediatric intensive care units (PICUs): A prospective study

Objective:

To determine the indication and necessity of echocardiographic assessment and therapeutic interventions in critically ill children.

Methods:

A total of 140 children, including 75 mechanically ventilated (MV) and 65 spontaneously breathing (SB) children, who were admitted consecutively from March to August 2013 were evaluated prospectively. Data regarding the indication for echocardiography and therapeutic approaches used were documented. For evaluating disease severity, the Pediatric Risk of Mortality Score III (PRISM) was ascertained. The correlation between PRISM score and the requirement of echocardiographic evaluations were analyzed.

Results:

Patients ages were between 45 days to 18 years. The male-to-female ratio was 1.33. In 35.4% patients who underwent echocardiographic evaluation, no definitive alteration occurred in treatment approach, whereas in the remaining 64.6% patients, decisive or supplemental information was gathered. Echocardiography was indicated in 88% MV children and 46.2% SB children. Echocardiographic evaluation was necessary in MV children and there was a positive correlation between the PRISM score and the requirement of echocardiographic assessment (p<0.001).

Conclusion:

Echocardiographic evaluation is an invaluable tool especially in MV children and the requirement of echocardiographic assessment increases according to clinical severity. Basic training for intensivists in this procedure is crucial and needs to be improved and supported in critically ill.

Pulmonary Hypertension and Vascular Abnormalities in Bronchopulmonary Dysplasia

Despite advances in the care of preterm infants, these infants remain at risk bronchopulmonary dysplasia (BPD), which results in prolonged need for supplemental oxygen, recurrent respiratory exacerbations, and exercise intolerance. Recent investigations have highlighted the important contribution of the developing pulmonary circulation to lung development, showing that these infants are also at risk for pulmonary vascular disease (PVD), including pulmonary hypertension (PH) and pulmonary vascular abnormalities. Several epidemiologic studies have delineated the incidence of PH in preterm infants and the impact on outcomes. These studies have also highlighted gaps in the understanding of PVD in BPD.

Monitoring of children with pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference

OBJECTIVE

To critically review the potential role of monitoring technologies in the management of pediatric acute respiratory distress syndrome, and specifically regarding monitoring of the general condition, respiratory system mechanics, severity scoring parameters, imaging, hemodynamic status, and specific weaning considerations.

DESIGN

Consensus conference of experts in pediatric acute lung injury.

METHODS

A panel of 27 experts met over the course of 2 years to develop a taxonomy to define pediatric acute respiratory distress syndrome and to make recommendations regarding treatment and research priorities. The monitoring subgroup comprised two experts. When published data were lacking a modified Delphi approach, emphasizing strong professional agreement was used.

RESULTS

The Pediatric Acute Lung Injury Consensus Conference experts developed and voted on a total of 151 recommendations addressing the topics related to pediatric acute respiratory distress syndrome, 21 of which related to monitoring of a child with pediatric acute respiratory distress syndrome. All 21 recommendations had agreement, with 19 (90%) reaching strong agreement.

CONCLUSIONS

The Consensus Conference developed pediatric-specific recommendations related to monitoring children with pediatric acute respiratory distress syndrome. These include interpreting monitored values such as tidal volume using predicted body weight, monitoring tidal volume at the end of the endotracheal tube in small children, and continuous monitoring of exhaled carbon dioxide in intubated children with pediatric acute respiratory distress syndrome, among others. These recommendations for monitoring in pediatric acute respiratory distress syndrome are intended to promote optimization and consistency of care for children with pediatric acute respiratory distress syndrome and identify areas of uncertainty requiring further investigation.

Nonpulmonary treatments for pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference

OBJECTIVE

To describe the recommendations from the Pediatric Acute Lung Injury Consensus Conference on nonpulmonary treatments in pediatric acute respiratory distress syndrome.

DESIGN

Consensus conference of experts in pediatric acute lung injury.

METHODS

A panel of 27 experts met over the course of 2 years to develop a taxonomy to define pediatric acute respiratory distress syndrome and to make recommendations regarding treatment and research priorities. The nonpulmonary subgroup comprised three experts. When published data were lacking, a modified Delphi approach emphasizing strong professional agreement was utilized.

RESULTS

The Pediatric Acute Lung Injury Consensus Conference experts developed and voted on a total of 151 recommendations addressing the topics related to pediatric acute respiratory distress syndrome, 30 of which related to nonpulmonary treatment. All 30 recommendations had strong agreement. Patients with pediatric acute respiratory distress syndrome should receive 1) minimal yet effective targeted sedation to facilitate mechanical ventilation; 2) neuromuscular blockade, if sedation alone is inadequate to achieve effective mechanical ventilation; 3) a nutrition plan to facilitate their recovery, maintain their growth, and meet their metabolic needs; 4) goal-directed fluid management to maintain adequate intravascular volume, end-organ perfusion, and optimal delivery of oxygen; and 5) goal-directed RBC transfusion to maintain adequate oxygen delivery. Future clinical trials in pediatric acute respiratory distress syndrome should report sedation, neuromuscular blockade, nutrition, fluid management, and transfusion exposures to allow comparison across studies.

CONCLUSIONS

The Consensus Conference developed pediatric-specific definitions for pediatric acute respiratory distress syndrome and recommendations regarding treatment and future research priorities. These recommendations for nonpulmonary treatment in pediatric acute respiratory distress syndrome are intended to promote optimization and consistency of care for patients with pediatric acute respiratory distress syndrome and identify areas of uncertainty requiring further investigation.

Estimating intracardiac and extracardiac shunting in the setting of complex congenital heart disease

Complex congenital heart disease (CHD) is associated with significant morbidity worldwide. Managing hypoxemia in these populations can be difficult, particularly in the setting of cyanotic CHD. However, the presence of additional extracardiac shunts secondary to acute respiratory disease can be very challenging to manage. Before understanding how to deal with hypoxemia in patients with dual shunts, one needs to understand the physiology and diagnosis related to the individual shunts and apply this knowledge to the patient as a whole.

Pulmonary vascular disease in bronchopulmonary dysplasia: pulmonary hypertension and beyond

PURPOSE OF REVIEW

Pulmonary hypertension contributes significantly to morbidity and mortality of chronic lung disease of infancy, or bronchopulmonary dysplasia (BPD). Advances in pulmonary vascular biology over the past few decades have led to new insights into the pathogenesis of BPD; however, many unique issues persist regarding our understanding of pulmonary vascular development and disease in preterm infants at risk for chronic lung disease.

RECENT FINDINGS

Recent studies have highlighted the important contribution of the developing pulmonary circulation to lung growth in the setting of preterm birth. These studies suggest that there is a spectrum of pulmonary vascular disease (PVD) in BPD rather than a simple question of whether or not pulmonary hypertension is present. Epidemiological studies underscore gaps in our understanding of PVD in the context of BPD, including universally accepted definitions, approaches to diagnosis and treatment, and patient outcomes. Unfortunately, therapeutic strategies for pulmonary hypertension in BPD are based on small observational studies with poorly defined endpoints and rely on results from older children and adult studies. Yet, unique characteristics of this population create other potential risks for the adoption of these strategies.

SUMMARY

Despite many recent advances, PVD remains an important contributor to poor outcomes in preterm infants with BPD. Substantial challenges persist, especially with regard to understanding mechanisms and the clinical approach to PVD. Future studies are needed to develop evidence-based definitions and clinical endpoints through which the pathophysiology can be investigated and potential therapeutic interventions evaluated.

Respiratory Impairment after Early Red Cell Transfusion in Pediatric Patients with ALI/ARDS

Introduction. In the first 48 hours of ventilating patients with acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), a multipronged approach including packed red blood cell (PRBC) transfusion is undertaken to maintain oxygen delivery. Hypothesis. We hypothesized children with ALI/ARDS transfused within 48 hours of initiating mechanical ventilation would have worse outcome. The course of 34 transfused patients was retrospectively compared to 45 nontransfused control patients admitted to the PICU at Helen DeVos Children's Hospital between January 1st 2008 and December 31st 2009. Results. Mean hemoglobin (Hb) prior to transfusion was 8.2 g/dl compared to 10.1 g/dl in control. P/F ratio decreased from 135.4 ± 7.5 to 116.5 ± 8.8 in transfused but increased from 148.0 ± 8.0 to 190.4 ± 17.8 (P < 0.001) in control. OI increased in the transfused from 11.7 ± 0.9 to 18.7 ± 1.6 but not in control. Ventilator days in the transfused were 15.6 ± 1.7 versus 9.5 ± 0.6 days in control (P < 0.001). There was a trend towards higher rates of MODS in transfused patients; 29.4% versus 17.7%, odds ratio 1.92, 95% CI; 0.6–5.6 Fisher exact P < 0.282. Conclusion. This study suggests that early transfusions of patients with ALI/ARDS were associated with increased ventilatory needs.