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Improved nutritional outcomes with neurally adjusted ventilatory assist (NAVA) in premature infants: a single tertiary neonatal unit's experience. Eur J Pediatr 2022; 181:2155-2159. [PMID: 35194652 PMCID: PMC9056442 DOI: 10.1007/s00431-022-04411-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/13/2022] [Accepted: 02/06/2022] [Indexed: 11/25/2022]
Abstract
During neurally adjusted ventilatory assist (NAVA)/non-invasive (NIV) NAVA, a modified nasogastric feeding tube with electrodes, monitors the electrical activity of the diaphragm (Edi). The Edi waveform determines the delivered pressure from the ventilator. Infant breathing is in synchrony with the ventilator and therefore is more comfortable with less work of breathing. Our aim was to determine if infants on NAVA had improved nutritional outcomes compared to infants managed on conventional respiratory support. A retrospective study was undertaken. Infants on NAVA were matched with two conventionally ventilated controls by gestational age, birth weight, sex, antenatal steroid exposure, and whether inborn or transferred ex utero. NAVA/NIV-NAVA was delivered by the SERVO-n® Maquet Getinge group ventilator. Conventional ventilation included pressure and volume control ventilation, and non-invasive ventilation included nasal intermittent positive pressure ventilation, triggered biphasic positive airway pressure, continuous positive airway pressure and heated humidified high flow oxygen. The measured outcome was discharge weight z scores. Eighteen "NAVA" infants with median gestational age (GA) of 25.3 (23.6-27.1) weeks and birth weight (BW) of 765 (580-1060) grams were compared with 36 controls with GA 25.2 (23.4-28) weeks (p = 0.727) and BW 743 (560-1050) grams (p = 0.727). There was no significant difference in the rates of postnatal steroids (61% versus 36% p = 0.093), necrotising enterocolitis (22% versus 11% p = 0.279) in the NAVA/NIV NAVA compared to the control group. There were slightly more infants who were breastfed at discharge in the NAVA/NIV NAVA group compared to controls: breast feeds (77.8% versus 58.3%), formula feeds (11.1% versus 30.6%), and mixed feeds (11.1% versus 11.1%), but this difference was not significant (p = 0.275). There was no significant difference in the birth z scores 0.235 (-1.56 to 1.71) versus -0.05 (-1.51 to -1.02) (p = 0.248) between the groups. However, the discharge z score was significantly in favour of the NAVA/NIV-NAVA group: -1.22 (-2.66 to -0.12) versus -2.17 (-3.79 to -0.24) in the control group (p = 0.033).Conclusion: The combination of NAVA/NIV-NAVA compared to conventional invasive and non-invasive modes may contribute to improved nutritional outcomes in premature infants.
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Araki R, Tomotaki S, Akita M, Motokura K, Tomobe Y, Yamauchi T, Hanaoka S, Tomotaki H, Iwanaga K, Niwa F, Takita J, Kawai M. Effect of electrical activity of the diaphragm waveform patterns on SpO 2 for extremely preterm infants ventilated with neurally adjusted ventilatory assist. Pediatr Pulmonol 2021; 56:2094-2101. [PMID: 33823078 DOI: 10.1002/ppul.25396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 03/27/2021] [Accepted: 03/27/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study aimed to evaluate the association between electrical activity of the diaphragm (Edi) waveform patterns and peripheral oxygen saturation (SpO2 ) in extremely preterm infants who are ventilated with neurally adjusted ventilatory assist (NAVA). STUDY DESIGN We conducted a retrospective cohort study at a level III neonatal intensive care unit. Extremely preterm infants born at our hospital between November 2019 and November 2020 and ventilated with NAVA were included. We collected Edi waveform data and classified them into four Edi waveform patterns, including the phasic pattern, central apnea pattern, irregular low-voltage pattern, and tonic burst pattern. We analyzed the Edi waveform pattern for the first 15 h of collectable data in each patient. To investigate the association between Edi waveform patterns and SpO2 , we analyzed the dataset every 5 min as one data unit. We compared the proportion of each waveform pattern between the desaturation (Desat [+]) and non-desaturation (Desat [-]) groups. RESULTS We analyzed collected data for 105 h (1260 data units). The proportion of the phasic pattern in the Desat (+) group was significantly lower than that in the Desat (-) group (p < .001). However, the proportions of the central apnea, irregular low-voltage, and tonic burst patterns in the Desat (+) group were significantly higher than those in the Desat (-) group (all p < .05). CONCLUSION Our results indicate that proportions of Edi waveform patterns have an effect on desaturation of SpO2 in extremely preterm infants who are ventilated with NAVA.
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Affiliation(s)
- Ryosuke Araki
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Seiichi Tomotaki
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Mitsuyo Akita
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kouji Motokura
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yutaro Tomobe
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeru Yamauchi
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shintaro Hanaoka
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroko Tomotaki
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kogoro Iwanaga
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Fusako Niwa
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Junko Takita
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masahiko Kawai
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Villosis MFB, Barseghyan K, Ambat MT, Rezaie KK, Braun D. Rates of Bronchopulmonary Dysplasia Following Implementation of a Novel Prevention Bundle. JAMA Netw Open 2021; 4:e2114140. [PMID: 34181013 PMCID: PMC8239950 DOI: 10.1001/jamanetworkopen.2021.14140] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
IMPORTANCE Bronchopulmonary dysplasia (BPD) rates in the United States remain high and have changed little in the last decade. OBJECTIVE To develop a consistent BPD prevention bundle in a systematic approach to decrease BPD. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study included 484 infants with birth weights from 501 to 1500 g admitted to a level 3 neonatal intensive care unit in the Kaiser Permanente Southern California system from 2009 through 2019. The study period was divided into 3 periods: 1, baseline (2009); 2, initial changes based on ongoing cycles of Plan-Do-Study-Act (2010-2014); and 3, full implementation of successive Plan-Do-Study-Act results (2015-2019). INTERVENTIONS A BPD prevention system of care bundle evolved with a shared mental model that BPD is avoidable. MAIN OUTCOMES AND MEASURES The primary outcome was BPD in infants with less than 33 weeks' gestational age (hereafter referred to as BPD <33). Other measures included adjusted BPD <33, BPD severity grade, and adjusted median postmenstrual age (PMA) at hospital discharge. Balancing measures were adjusted mortality and adjusted mortality or specified morbidities. RESULTS The study population included 484 infants with a mean (SD) birth weight of 1070 (277) g; a mean (SD) gestational age of 28.6 (2.9) weeks; 252 female infants (52.1%); and 61 Black infants (12.6%). During the 3 study periods, BPD <33 decreased from 9 of 29 patients (31.0%) to 3 of 184 patients (1.6%) (P < .001 for trend); special cause variation was observed. The standardized morbidity ratio for the adjusted BPD <33 decreased from 1.2 (95% CI, 0.7-1.9) in 2009 to 0.4 (95% CI, 0.2-0.8) in 2019. The rates of combined grades 1, 2, and 3 BPD decreased from 7 of 29 patients (24.1%) to 17 of 183 patients (9.3%) (P < .008 for trend). Grade 2 BPD rates decreased from 3 of 29 patients (10.3%) to 5 of 183 patients (2.7%) (P = .02 for trend). Adjusted median PMA at home discharge decreased by 2 weeks, from 38.2 (95% CI, 37.3-39.1) weeks in 2009 to 36.8 (95% CI, 36.6-37.1) weeks during the last 3 years (2017-2019) of the full implementation period. Adjusted mortality was unchanged, whereas adjusted mortality or specified morbidities decreased significantly. CONCLUSIONS AND RELEVANCE A sustained low rate of BPD was observed in infants after the implementation of a detailed BPD system of care.
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Affiliation(s)
- Maria Fe B. Villosis
- Department of Pediatrics (Neonatology), Kaiser Permanente Panorama City, Panorama City, California
| | - Karine Barseghyan
- Department of Pediatrics (Neonatology), Kaiser Permanente Panorama City, Panorama City, California
| | - Ma. Teresa Ambat
- Department of Pediatrics (Neonatology), Kaiser Permanente Panorama City, Panorama City, California
| | - Kambiz K. Rezaie
- Department of Pediatrics (Neonatology), Kaiser Permanente Panorama City, Panorama City, California
| | - David Braun
- Department of Pediatrics (Neonatology), Kaiser Permanente Panorama City, Panorama City, California
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
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Protain AP, Firestone KS, McNinch NL, Stein HM. Evaluating peak inspiratory pressures and tidal volume in premature neonates on NAVA ventilation. Eur J Pediatr 2021; 180:167-175. [PMID: 32627057 PMCID: PMC7335731 DOI: 10.1007/s00431-020-03728-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/11/2020] [Accepted: 06/29/2020] [Indexed: 12/02/2022]
Abstract
Neurally adjusted ventilatory assist (NAVA) ventilation allows patients to determine their peak inspiratory pressure and tidal volume on a breath-by-breath basis. Apprehension exists about premature neonates' ability to self-regulate breath size. This study describes peak pressure and tidal volume distribution of neonates on NAVA and non-invasive NAVA. This is a retrospective study of stored ventilator data with exploratory analysis. Summary statistics were calculated. Distributional assessment of peak pressure and tidal volume were evaluated, overall and per NAVA level. Over 1 million breaths were evaluated from 56 subjects. Mean peak pressure was 16.4 ± 6.4 in the NAVA group, and 15.8 ± 6.4 in the NIV-NAVA group (t test, p < 0.001). Mean tidal volume was 3.5 ± 2.7 ml/kg.Conclusion:In neonates on NAVA, most pressures and volumes were within or lower than recommended ranges with pressure-limited or volume-guarantee ventilation. What is known: • Limiting peak inspiratory pressures or tidal volumes are the main strategies to minimize ventilator-induced lung injury in neonates. Neurally adjusted ventilatory assist allows neonates to regulate their own peak inspiratory pressures and tidal volumes on a breath-to-breath basis using neural feedback. What is new: • When neonates chose the size of their breaths based on neural feedback, the majority of peak inspiratory pressures and tidal volumes were within or lower than the recommended peak inspiratory pressure or tidal volume ranges with pressure-limited or volume guarantee ventilation.
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Affiliation(s)
- Alison P. Protain
- Pediatrix Medical Group, Akron, OH USA
- Akron Children’s Hospital, Akron, OH USA
| | | | - Neil L. McNinch
- Akron Children’s Hospital, Akron, OH USA
- Rebecca D. Considine Research Institute, Akron Children’s Hospital, Akron, OH USA
| | - Howard M. Stein
- ProMedica Ebeid Children’s Hospital, Toledo, OH USA
- University of Toledo Health Science Campus, Toledo, OH USA
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Hussain WA, Marks JD. Approaches to Noninvasive Respiratory Support in Preterm Infants: From CPAP to NAVA. Neoreviews 2019; 20:e213-e221. [PMID: 31261062 DOI: 10.1542/neo.20-4-e213] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Endotracheal intubation and invasive mechanical ventilation have been mainstays in respiratory care of neonates with respiratory distress syndrome. Together with antenatal steroids and surfactant, this approach has accounted for significant reductions in neonatal mortality. However, with the increased survival of very low birthweight infants, the incidence of bronchopulmonary dysplasia (BPD), the primary respiratory morbidity of prematurity, has also increased. Arrest of alveolar growth and development and the abnormal development of the pulmonary vasculature after birth are the primary causes of BPD. However, invasive ventilation-associated lung inflammation and airway injury have long been believed to be important contributors. In fact, discontinuing invasive ventilation in favor of noninvasive respiratory support has been considered the single best approach that neonatologists can implement to reduce BPD. In this review, we present and discuss the mechanisms, efficacy, and long-term outcomes of the four main approaches to noninvasive respiratory support of the preterm infant currently in use: nasal continuous positive airway pressure, high-flow nasal cannula, nasal intermittent mandatory ventilation, and neurally adjusted ventilatory assist. We show that noninvasive ventilation can decrease rates of intubation and the need for invasive ventilation in preterm infants with respiratory distress syndrome. However, none of these noninvasive approaches decrease rates of BPD. Accordingly, noninvasive respiratory support should be considered for clinical goals other than the reduction of BPD.
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Affiliation(s)
- Walid A Hussain
- Section of Neonatology, Department of Pediatrics, University of Chicago, Chicago, IL
| | - Jeremy D Marks
- Section of Neonatology, Department of Pediatrics, University of Chicago, Chicago, IL.,Committee on Neurobiology, Department of Neurology, University of Chicago, Chicago, IL
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Colleti Junior J, Koga W, Carvalho WBD. SÍNDROME POSTERIOR DO TRONCO CEREBRAL E O USO DE VENTILAÇÃO ASSISTIDA AJUSTADA NEURALMENTE (NAVA) EM LACTENTE. REVISTA PAULISTA DE PEDIATRIA 2017; 36:4. [PMID: 28977137 PMCID: PMC5849368 DOI: 10.1590/1984-0462/;2018;36;1;00003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 03/26/2017] [Indexed: 11/21/2022]
Abstract
Objective: To report a rare case of dorsal brainstem syndrome in an infant after
hypoxic-ischemic episode due to severe sepsis and the use of neurally adjusted
ventilatory assist (NAVA) to aid in diagnosis and in the removal of mechanical
ventilation. Case description: A 2-month-old male infant, previously healthy, presented with severe sepsis that
evolved to dorsal brainstem syndrome, which usually occurs after hypoxic-ischemic
injury in neonates and infants, and is related to very specific magnetic resonance
images. Due to neurological lesions, thei nfant remained in mechanical
ventilation. A NAVA module was installed to keep track of phrenic nerve conduction
to the diaphragm, having successfully showed neural conduction and helped removing
mechanical ventilation. Comments: Dorsal brainstem syndrome is a rare condition that should be considered after
hypoxic-ischemic episode in infants.
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Abstract
Morbidity and mortality have decreased in patients with neuromuscular disease due to implementation of therapies to augment cough and improve ventilation. Infants with progressive neuromuscular disease will eventually develop respiratory complications as a result of muscle weakness and their inability to compensate during periods of increased respiratory loads. The finding of nocturnal hypercapnia is often the trigger for initiating non-invasive ventilation and studies have shown that its use not only may improve sleep-disordered breathing, but also that it may have an effect on daytime function, symptoms related to hypercapnia, and partial pressure of CO2. It is important to understand the respiratory physiology of this population and to understand the benefits and limitations of assisted ventilation.
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Affiliation(s)
- Stamatia Alexiou
- Division of Pulmonary Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Joseph Piccione
- Division of Pulmonary Medicine & Center for Pediatric Airway Disorders, Philadelphia, PA, USA
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Reiterer F, Schwaberger B, Freidl T, Schmölzer G, Pichler G, Urlesberger B. Lung-protective ventilatory strategies in intubated preterm neonates with RDS. Paediatr Respir Rev 2017; 23:89-96. [PMID: 27876355 DOI: 10.1016/j.prrv.2016.10.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 10/20/2016] [Indexed: 11/16/2022]
Abstract
This article provides a narrative review of lung-protective ventilatory strategies (LPVS) in intubated preterm infants with RDS. A description of strategies is followed by results on short-and long-term respiratory and neurodevelopmental outcomes. Strategies will include patient-triggered or synchronized ventilation, volume targeted ventilation, the technique of intubation, surfactant administration and rapid extubation to NCPAP (INSURE), the open lung concept, strategies of high-frequency ventilation, and permissive hypercapnia. Based on this review single recommendations on optimal LPVS cannot be made. Combinations of several strategies, individually applied, most probably minimize or avoid potential serious respiratory and cerebral complications like bronchopulmonary dysplasia and cerebral palsy.
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Affiliation(s)
- F Reiterer
- Division of Neonatology, Department of Pediatrics and Adolescence Medicine, Medical University Graz, Austria.
| | - B Schwaberger
- Division of Neonatology, Department of Pediatrics and Adolescence Medicine, Medical University Graz, Austria
| | - T Freidl
- Division of Neonatology, Department of Pediatrics and Adolescence Medicine, Medical University Graz, Austria
| | - G Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada; Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - G Pichler
- Division of Neonatology, Department of Pediatrics and Adolescence Medicine, Medical University Graz, Austria
| | - B Urlesberger
- Division of Neonatology, Department of Pediatrics and Adolescence Medicine, Medical University Graz, Austria
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Neurally Adjusted Ventilatory Assist in Preterm Infants With Established or Evolving Bronchopulmonary Dysplasia on High-Intensity Mechanical Ventilatory Support: A Single-Center Experience. Pediatr Crit Care Med 2016; 17:1142-1146. [PMID: 27918385 DOI: 10.1097/pcc.0000000000000981] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVES The aim of the present study was to report possible improvements in ventilator variables associated with a transition from synchronized intermittent mandatory ventilation to neurally adjusted ventilatory assist in preterm infants with bronchopulmonary dysplasia who required a high level of mechanical ventilatory support in a single center. DESIGN Retrospective study. SETTING Neonatal ICU. PATIENTS Twenty-nine preterm infants with a median gestational age of 25.4 weeks (range, 23.4-30.3 wk) and a median birth weight of 680 g (range, 370-1,230 g) and who were supported with a mechanical ventilator for more than 4 weeks and had a respiratory severity score greater than four during conventional mechanical ventilation prior to conversion to neurally adjusted ventilatory assist. INTERVENTIONS Comparison of ventilatory variables, work of breathing, and blood gas values during conventional ventilation and at various time intervals after the change to neurally adjusted ventilatory assist. MEASUREMENTS AND MAIN RESULTS The values of various ventilatory variables and other measurements were obtained 1 hour before neurally adjusted ventilatory assist and 1, 4, 12, and 24 hours after conversion to neurally adjusted ventilatory assist. During neurally adjusted ventilatory assist, the peak inspiratory pressure (20.12 ± 2.93 vs 14.15 ± 3.55 cm H2O; p < 0.05), mean airway pressure (11.15 ± 1.29 vs 9.57 ± 1.27 cm H2O; p < 0.05), and work of breathing (0.86 ± 0.22 vs 0.46 ± 0.12 J/L; p < 0.05) were significantly decreased, and the blood gas values were significantly improved. Significantly lower FIO2 and improved oxygen saturation were observed during neurally adjusted ventilatory assist compared with conventional ventilation support. The RSS values decreased and sustained during neurally adjusted ventilatory assist (4.85 ± 1.63 vs 3.21 ± 1.01; p < 0.001). CONCLUSIONS The transition from synchronized intermittent mandatory ventilation to neurally adjusted ventilatory assist ventilation was associated with improvements in ventilator variables, oxygen saturation, and blood gas values in infants with bronchopulmonary dysplasia in a single center. This study suggests the possible clinical utility of neurally adjusted ventilatory assist as a weaning modality for bronchopulmonary dysplasia patients in the neonatal ICU.
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Wright CJ, Polin RA, Kirpalani H. Continuous Positive Airway Pressure to Prevent Neonatal Lung Injury: How Did We Get Here, and How Do We Improve? J Pediatr 2016; 173:17-24.e2. [PMID: 27025910 DOI: 10.1016/j.jpeds.2016.02.059] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 01/25/2016] [Accepted: 02/24/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Clyde J Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO.
| | - Richard A Polin
- College of Physicians and Surgeons, Columbia University, New York, NY
| | - Haresh Kirpalani
- Division of Neonatology, The Children's Hospital of Philadelphia at the University of Pennsylvania, Philadelphia, PA
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Abstract
Non-invasive ventilation (NIV) is used in neonates to treat extrathoracic and intrathoracic airway obstruction, parenchymal lung disease and disorders of control of breathing. Avoidance of airway intubation is associated with a reduction in the incidence of chronic lung disease among preterm infants with respiratory distress syndrome. Use of nasal continuous positive airway pressure (nCPAP) may help establish and maintain functional residual capacity (FRC), decrease respiratory work, and improve gas exchange. Other modes of non-invasive ventilation, which include heated humidified high-flow nasal cannula therapy (HHHFNC), nasal intermittent mandatory ventilation (NIMV), non-invasive pressure support ventilation (NI-PSV), and bi-level CPAP (SiPAP™), have also been shown to provide additional benefit in improving breathing patterns, reducing work of breathing, and increasing gas exchange when compared with nCPAP. Newer modes, such as neurally adjusted ventilatory assist (NAVA), hold the promise of improving patient-ventilator synchrony and so might ultimately improve outcomes for preterm infants with respiratory distress.
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Affiliation(s)
- Stamatia Alexiou
- Division of Pulmonary Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Howard B Panitch
- The Perelman School of Medicine at The University of Pennsylvania, Division of Pulmonary Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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