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Quach S, Reise K, McGregor C, Papaconstantinou E, Nonoyama ML. A Delphi Survey of Canadian Respiratory Therapists' Practice Statements on Pediatric Mechanical Ventilation. Respir Care 2022; 67:1420-1436. [PMID: 35922069 PMCID: PMC9993971 DOI: 10.4187/respcare.09886] [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: 11/05/2022]
Abstract
BACKGROUND Pediatric mechanical ventilation practice guidelines are not well established; therefore, the European Society for Paediatric and Neonatal Intensive Care (ESPNIC) developed consensus recommendations on pediatric mechanical ventilation management in 2017. However, the guideline's applicability in different health care settings is unknown. This study aimed to determine the consensus on pediatric mechanical ventilation practices from Canadian respiratory therapists' (RTs) perspectives and consensually validate aspects of the ESPNIC guideline. METHODS A 3-round modified electronic Delphi survey was conducted; contents were guided by ESPNIC. Participants were RTs with at least 5 years of experience working in standalone pediatric ICUs or units with dedicated pediatric intensive care beds across Canada. Round 1 collected open-text feedback, and subsequent rounds gathered feedback using a 6-point Likert scale. Consensus was defined as ≥ 75% agreement; if consensus was unmet, statements were revised for re-ranking in the subsequent round. RESULTS Fifty-two RTs from 14 different pediatric facilities participated in at least one of the 3 rounds. Rounds 1, 2, and 3 had a response rate of 80%, 93%, and 96%, respectively. A total of 59 practice statements achieved consensus by the end of round 3, categorized into 10 sections: (1) noninvasive ventilation and high-flow oxygen therapy, (2) tidal volume and inspiratory pressures, (3) breathing frequency and inspiratory times, (4) PEEP and FIO2 , (5) advanced modes of ventilation, (6) weaning, (7) physiological targets, (8) monitoring, (9) general, and (10) equipment adjuncts. Cumulative text feedback guided the formation of the clinical remarks to supplement these practice statements. CONCLUSIONS This was the first study to survey RTs for their perspectives on the general practice of pediatric mechanical ventilation management in Canada, generally aligning with the ESPNIC guideline. These practice statements considered information from health organizations and institutes, supplemented with clinical remarks. Future studies are necessary to verify and understand these practices' effectiveness.
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Affiliation(s)
- Shirley Quach
- The Hospital for Sick Children, Department of Respiratory Therapy, Toronto, Ontario, Canada; McMaster University, School of Rehabilitation Sciences, Institute for Applied Health Sciences, Hamilton, Ontario, Canada; and Ontario Tech University, Faculty of Health Sciences, Oshawa, Ontario, Canada
| | - Katherine Reise
- The Hospital for Sick Children, Department of Respiratory Therapy, Toronto, Ontario, Canada
| | - Carolyn McGregor
- Ontario Tech University, Faculty of Health Sciences, Oshawa, Ontario, Canada; and University of Technology, Sydney, New South Wales, Australia
| | | | - Mika L Nonoyama
- The Hospital for Sick Children, Department of Respiratory Therapy, Toronto, Ontario, Canada; and Ontario Tech University, Faculty of Health Sciences, Oshawa, Ontario, Canada.
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2
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Miller AG, Scott BL. 2021 Year in Review: Pediatric Mechanical Ventilation. Respir Care 2022; 67:1476-1488. [PMID: 36100276 PMCID: PMC9993959 DOI: 10.4187/respcare.10311] [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: 11/05/2022]
Abstract
Mechanical ventilation is commonly used in the pediatric intensive care unit. This paper reviews studies of pediatric mechanical ventilation published in 2021. Topics include physiology, ventilator modes, alarms, disease states, airway suctioning, ventilator liberation, prolonged ventilation, and others.
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Affiliation(s)
- Andrew G Miller
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina; and Respiratory Care Services, Duke University Medical Center, Durham, North Carolina.
| | - Briana L Scott
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
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White BR, Cadotte N, McClellan EB, Presson AP, Bennett E, Smith AG, Aljabari S. High-Frequency Percussive Ventilation in Viral Bronchiolitis. Respir Care 2022; 67:781-788. [PMID: 35580910 PMCID: PMC9994098 DOI: 10.4187/respcare.09350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND High-frequency percussive ventilation (HFPV) is an alternative mode of mechanical ventilation that has been shown to improve gas exchange in subjects with severe respiratory failure. We hypothesized that HFPV use would improve ventilation and oxygenation in intubated children with acute bronchiolitis. METHODS In this single-center prospective cohort study we included mechanically ventilated children in the pediatric ICU with bronchiolitis 1-24 months old who were transitioned to HFPV from conventional invasive mechanical ventilation from November 2018-April 2020. Patients with congenital heart disease, on extracorporeal membrane oxygenation (ECMO), and with HFPV duration < 12 h were excluded. Subject gas exchange metrics and ventilator parameters were compared before and after HFPV initiation. RESULTS Forty-one of 192 (21%) patients intubated with bronchiolitis underwent HFPV, and 35 met inclusion criteria. Median age of cohort was 4 months, and 60% were previously healthy. All subjects with available oxygenation saturation index (OSI) measurements pre-HFPV met pediatric ARDS criteria (31/35, 89%). Mean CO2 decreased from 65.4 in the 24 h pre-HFPV to 51 (P < .001) in the 24 h post initiation. SpO2 /FIO2 was significantly improved at 24 h post-HFPV (153.3 to 209.7, P = .001), whereas the decrease in mean OSI at 24 h did not meet statistical significance (11.9 to 10.2, P = .15). The mean peak inspiratory pressure (PIP) decreased post-HFPV from 29.7 to 25.0 at 24 h (P < .001). No subjects developed an air leak or hemodynamic instability secondary to HFPV. Two subjects required ECMO, and of these, one subject died. CONCLUSIONS HFPV was associated with significant improvement in ventilation and decreased exposure to high PIPs for mechanically ventilated children with bronchiolitis in our cohort and had a potential association with improved oxygenation. Our study shows that HFPV may be an effective alternative mode of ventilation in patients with bronchiolitis who have poor gas exchange on conventional invasive mechanical ventilation.
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Affiliation(s)
- Benjamin R White
- Department of Pediatrics, Division of Pediatric Critical Care, Penn State Health Children's Hospital, Hershey, Pennsylvania.
| | - Noelle Cadotte
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, Utah
| | - Eric B McClellan
- Department of Pediatrics, Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Angela P Presson
- Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, Utah
| | - Erin Bennett
- Department of Pediatrics, Division of Critical Care, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Andrew G Smith
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, Utah
| | - Salim Aljabari
- Department of Pediatrics, Division of Pediatric Critical Care, University of Missouri, Columbia, Missouri
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Kollisch-Singule M, Ramcharran H, Satalin J, Blair S, Gatto LA, Andrews PL, Habashi NM, Nieman GF, Bougatef A. Mechanical Ventilation in Pediatric and Neonatal Patients. Front Physiol 2022; 12:805620. [PMID: 35369685 PMCID: PMC8969224 DOI: 10.3389/fphys.2021.805620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 12/15/2021] [Indexed: 11/30/2022] Open
Abstract
Pediatric acute respiratory distress syndrome (PARDS) remains a significant cause of morbidity and mortality, with mortality rates as high as 50% in children with severe PARDS. Despite this, pediatric lung injury and mechanical ventilation has been poorly studied, with the majority of investigations being observational or retrospective and with only a few randomized controlled trials to guide intensivists. The most recent and universally accepted guidelines for pediatric lung injury are based on consensus opinion rather than objective data. Therefore, most neonatal and pediatric mechanical ventilation practices have been arbitrarily adapted from adult protocols, neglecting the differences in lung pathophysiology, response to injury, and co-morbidities among the three groups. Low tidal volume ventilation has been generally accepted for pediatric patients, even in the absence of supporting evidence. No target tidal volume range has consistently been associated with outcomes, and compliance with delivering specific tidal volume ranges has been poor. Similarly, optimal PEEP has not been well-studied, with a general acceptance of higher levels of FiO2 and less aggressive PEEP titration as compared with adults. Other modes of ventilation including airway pressure release ventilation and high frequency ventilation have not been studied in a systematic fashion and there is too little evidence to recommend supporting or refraining from their use. There have been no consistent outcomes among studies in determining optimal modes or methods of setting them. In this review, the studies performed to date on mechanical ventilation strategies in neonatal and pediatric populations will be analyzed. There may not be a single optimal mechanical ventilation approach, where the best method may simply be one that allows for a personalized approach with settings adapted to the individual patient and disease pathophysiology. The challenges and barriers to conducting well-powered and robust multi-institutional studies will also be addressed, as well as reconsidering outcome measures and study design.
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Affiliation(s)
| | - Harry Ramcharran
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Joshua Satalin
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
- *Correspondence: Joshua Satalin,
| | - Sarah Blair
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Louis A. Gatto
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Penny L. Andrews
- Department of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Nader M. Habashi
- Department of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Gary F. Nieman
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Adel Bougatef
- Independent Researcher, San Antonio, TX, United States
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5
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Miller AG, Scott BL, Gates RM, Haynes KE, Lopez Domowicz DA, Rotta AT. High-Frequency Jet Ventilation in Infants With Congenital Heart Disease. Respir Care 2021; 66:1684-1690. [PMID: 34108137 PMCID: PMC9993543 DOI: 10.4187/respcare.09186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND High-frequency jet ventilation (HFJV) is primarily used in neonates but may also have a role in the treatment of infants with congenital heart disease and severe respiratory failure. We hypothesized that HFJV would result in improved gas exchange in these infants. METHODS We retrospectively reviewed the records of all pediatric patients with complex congenital heart disease treated HFJV in our pediatric cardiac ICU between 2014 and 2018. Patients in whom HFJV was started while on extracorporeal membrane oxygenation (ECMO) were excluded. We extracted data on demographics, pulmonary mechanics, gas exchange, the subsequent need for ECMO, use of inhaled nitric oxide, and outcomes. RESULTS We included 27 subjects (median [interquartile range {IQR}] weight 4.4 [3.3-5.4] kg; median [IQR] age 2.5 [0.3-5.4] months), 22 (82%) of whom had cyanotic heart disease. Thirteen subjects (48%) survived and 6 (22%) required ECMO. HFJV was started after a median (IQR) of 8.4 (2.1-26.3) d of conventional mechanical ventilation. The subjects spent a median (IQR) of 1.2 (0.5-2.8) d on HFJV. The median (IQR) pre-HFJV blood gas results (n = 25) were pH 7.22 (7.17-7.31), [Formula: see text] 69 (51-77) mm Hg, and [Formula: see text] 51 (41-76) mm Hg. Median (IQR) initial HFJV settings were peak inspiratory pressure of 45 (36-50) cm H2O, breathing frequency of 360 (360-380) breaths/min, and inspiratory time of 0.02 (0.02-0.03) s. Compared with conventional mechanical ventilation, at 4-6 h after HFJV initiation, there were significant improvements in the median pH (7.22 vs 7.34; P = .001) and [Formula: see text] (69 vs 50 mm Hg; P = .001), respectively, but no difference in median [Formula: see text] (51 vs 53 mm Hg; P = .97). CONCLUSIONS HFJV was associated with a decrease in [Formula: see text] and an increase in pH in infants with congenital heart disease who remained on HFJV 4 to 6 h after initiation.
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Affiliation(s)
- Andrew G Miller
- Respiratory Care Services, Duke University Medical Center, Durham, North Carolina.
| | - Briana L Scott
- Division of Pediatric Critical Care Medicine, Duke Children's Hospital, Durham, North Carolina
| | - Rachel M Gates
- Respiratory Care Services, Duke University Medical Center, Durham, North Carolina
| | - Kaitlyn E Haynes
- Respiratory Care Services, Duke University Medical Center, Durham, North Carolina
| | - Denise A Lopez Domowicz
- Division of Pediatric Critical Care Medicine, Duke Children's Hospital, Durham, North Carolina
| | - Alexandre T Rotta
- Division of Pediatric Critical Care Medicine, Duke Children's Hospital, Durham, North Carolina
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6
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Miller AG, Bartle RM, Feldman A, Mallory P, Reyes E, Scott B, Rotta AT. A narrative review of advanced ventilator modes in the pediatric intensive care unit. Transl Pediatr 2021; 10:2700-2719. [PMID: 34765495 PMCID: PMC8578787 DOI: 10.21037/tp-20-332] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 11/26/2020] [Indexed: 01/29/2023] Open
Abstract
Respiratory failure is a common reason for pediatric intensive care unit admission. The vast majority of children requiring mechanical ventilation can be supported with conventional mechanical ventilation (CMV) but certain cases with refractory hypoxemia or hypercapnia may require more advanced modes of ventilation. This paper discusses what we have learned about the use of advanced ventilator modes [e.g., high-frequency oscillatory ventilation (HFOV), high-frequency percussive ventilation (HFPV), high-frequency jet ventilation (HFJV) airway pressure release ventilation (APRV), and neurally adjusted ventilatory assist (NAVA)] from clinical, animal, and bench studies. The evidence supporting advanced ventilator modes is weak and consists of largely of single center case series, although a few RCTs have been performed. Animal and bench models illustrate the complexities of different modes and the challenges of applying these clinically. Some modes are proprietary to certain ventilators, are expensive, or may only be available at well-resourced centers. Future efforts should include large, multicenter observational, interventional, or adaptive design trials of different rescue modes (e.g., PROSpect trial), evaluate their use during ECMO, and should incorporate assessments through volumetric capnography, electric impedance tomography, and transpulmonary pressure measurements, along with precise reporting of ventilator parameters and physiologic variables.
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Affiliation(s)
- Andrew G Miller
- Duke University Medical Center, Durham, NC, USA.,Respiratory Care Services, Duke University Medical Center, Durham, NC, USA
| | - Renee M Bartle
- Duke University Medical Center, Durham, NC, USA.,Respiratory Care Services, Duke University Medical Center, Durham, NC, USA
| | - Alexandra Feldman
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Palen Mallory
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Edith Reyes
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Briana Scott
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Alexandre T Rotta
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
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7
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Miller AG, Bartle RM, Rehder KJ. High-Frequency Jet Ventilation in Neonatal and Pediatric Subjects: A Narrative Review. Respir Care 2021; 66:845-856. [PMID: 33931517 PMCID: PMC9994116 DOI: 10.4187/respcare.08691] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
High-frequency ventilation is commonly utilized with neonates and with children with severe respiratory failure. Both high-frequency oscillatory ventilation (HFOV) and high-frequency jet ventilation (HFJV) are used extensively in neonates. HFJV can also be used in older, larger children. The purpose of this narrative review is to discuss the physiologic principles behind HFJV, examine the evidence supporting its use in neonatal and pediatric ICUs, give meaningful guidance for clinical application, and highlight potential areas for future research.
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Affiliation(s)
- Andrew G Miller
- Respiratory Care Services, Duke University Medical Center, Durham, North Carolina.
| | - Renee M Bartle
- Respiratory Care Services, Duke University Medical Center, Durham, North Carolina
| | - Kyle J Rehder
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
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8
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Maxwell AR, Frazier M, Varisco BM. High-Frequency Jet Ventilation Is Making Slow Inroads to the Pediatric ICU. Respir Care 2021; 66:349-350. [PMID: 33514662 PMCID: PMC9994233 DOI: 10.4187/respcare.08797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Andrea R Maxwell
- Department of Pediatrics Division of Critical Care MedicineCincinnati Children's Hospital Medical CenterCincinnati, Ohio
| | - Maria Frazier
- Department of Pediatrics Division of Critical Care MedicineCincinnati Children's Hospital Medical CenterCincinnati, Ohio
| | - Brian M Varisco
- Department of PediatricsDivision of Critical Care MedicineCincinnati Children's Hospital Medical CenterCincinnati, OhioUniversity of Cincinnati College of MedicineCincinnati, Ohio
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