Comparison of nasal intermittent positive pressure ventilation and bubble CPAP with an in-line high-frequency interrupter in a premature infant lung model

INTRODUCTION

Noninvasive ventilation has become a staple in the care of premature infants. However, failure rates continue to be high in this population. Modifications to noninvasive support, such as nasal intermittent positive pressure ventilation (NIPPV), are used clinically to reduce such failure. Previous in vitro studies have shown improved CO₂ clearance when superimposing high-frequency oscillations onto bubble continuous positive airway pressure (BCPAP).

OBJECTIVE

To compare the CO₂ clearance of NIPPV to BCPAP with an in-line high-frequency interrupter (HFI) in a premature infant lung model.

METHODS

A premature infant lung model was connected to either a Dräger VN500 for delivery of NIPPV or a BCPAP device with superimposed high-frequency oscillations generated by an in-line HFI. Change in end-tidal CO₂  (ETCO₂ ) and mean airway pressure at the simulated trachea were measured and compared for both noninvasive modalities.

RESULTS

Superimposing HF oscillations onto BCPAP with an in-line HFI resulted in improved CO₂ clearance relative to BCPAP alone for all tested oscillation frequencies at all CPAP levels (p < 0.001). NIPPV also resulted in improved CO₂  clearance relative to nasal CPAP (NCPAP) alone (p < 0.001). Among the tested settings, BCPAP with an in-line HFI resulted in decreased ETCO₂ relative to BCPAP ranging from -14% to -36%, while NIPPV resulted in decreased ETCO₂  relative to NCPAP ranging from -2% to -12%.

CONCLUSION

Superimposing high-frequency oscillations onto BCPAP using a novel in-line HFI was found to be more effective at clearing CO₂ than NIPPV in a premature infant lung model.

The Role of Care Coordinators for Children with Respiratory Technologies and Home Nursing

Background: Children with respiratory technologies, particularly those with mechanical ventilation, represent a growing population that require complex home nursing, medical equipment, outpatient medical and habilitative supports to live and thrive in their community. Care coordination is essential to support these children and their families to navigate and integrate key community-based health and educational services, however, care is often fragmented and care coordination needs unmet. Therefore, to fully support children with respiratory technologies, it is critical to understand the role of care coordinators (CCs) and how to sustain this workforce. The aim of this article is to describe CCs' perspective on (1) their role in supporting families in a home care program for children with respiratory technologies and home nursing, and (2) the core components of recruiting into and sustaining the CC workforce. Methods: Semistructured interviews were conducted with 15 CC from the Division of Specialized Care for Children (DSCC) Home Care program for children with technology dependence and home nursing in Illinois. Two independent coders utilized a modified template approach and discussed to agreement to analyze transcripts. Results: CC averaged 6.6 years of CC experience; the majority had social work or nursing backgrounds. CCs' job satisfaction was derived from their role supporting hospital discharge, seeing children improve over time, and navigating challenges with families. CCs enjoyed working in a collaborative environment where they could draw from their colleagues' experience to solve problems. Job dissatisfaction and job turnover stemmed from difficult family interactions, high caseloads, and redundant and time-intensive administrative tasks, which interfered with family engagement. Conclusions: CCs for children with respiratory technologies require diverse skills, but interdisciplinary teams enable collaborative support of families. Seeing children thrive can sustain the workforce, however, CCs report challenges due to high caseloads and administrative tasks, which impede direct family involvement.

Pediatric tracheostomy tube decannulation with or without polysomnography: A PRO-CON debate

Determining the timing for decannulation in children with a tracheostomy is a complex process, as the appropriate timing varies based on the initial indication for the tracheostomy tube as well as individual patient characteristics. The original condition for which a tracheostomy was created may improve over time with decannulation being a very important long-term goal for many families and multidisciplinary teams. However, decannulation is an inherently risky procedure associated with morbidity and mortality. Therefore, careful planning is required to ensure the safety of the procedure. Although routine airway endoscopy is an important component of decannulation protocols, guidelines are less prescriptive regarding the definition of a complete endoscopic airway evaluation and the routine use of polysomnography. This review will summarize the important PRO and CON arguments of integrating polysomnography into pediatric decannulation protocols.

Efficacy of standardized tracheostomy training with a simulation model for healthcare providers: A study by ISPAT team

INTRODUCTION

Tracheostomy care in children may be challenging, due to lack of knowledge of healthcare providers (HCPs). The aim of this study was to determine the level of knowledge of HCP who follow patients with tracheostomy and to increase this level with theoretical training and training in a simulation laboratory.

MATERIALS AND METHODS

ISPAT (IStanbul PAediatric Tracheostomy), a multidisciplinary team for tracheostomy care was established and a training program was prepared. Participants were subjected to theoretical and practical pretests which evaluated their knowledge levels and skills for care, follow-up, and treatment of a patient with tracheostomy. After the theoretical and practical training given to the participants with a simulation model, theoretical and practical posttests were applied.

RESULTS

Fifty-one HCP from nine tertiary pediatric clinics in Istanbul were enrolled in the training program. Only six (11.8%) of them had received standardized training programs previously. Regarding the theoretical tests, seven of the 33 questions were indicated as essential. The knowledge level of the participants based on the essential questions significantly increased after the training (p < 0.05 for all of the essential questions). The total number of correct answers and correct answers of three subheadings also significantly increased after the practical training (p < 0.001 for all). Ninety-five percent of the participants assessed the course as good or excellent in general.

CONCLUSION

Training in a simulation laboratory in combination with theoretical education can improve the knowledge and skills of the HCP enabling improved care of children with a tracheostomy.

Cystic fibrosis year in review 2020: Section 2 pulmonary disease, infections, and inflammation

The outlook for those with cystic fibrosis (CF) has never been brighter with ever increasing life expectancy and the approval of the highly effective CFTR modulators, such as elexacaftor/tezacaftor/ivacaftor. With that being said, the progressive pulmonary decline and importance of lung health, infection, and inflammation in CF remains. This review is the second part in a three-part CF Year in Review 2020. Part one focused on the literature related to CFTR modulators while part three will feature the multisystem effects related to CF. This review focuses on articles from Pediatric Pulmonology, including articles from other journals that are of particular interest to clinicians. Herein, we highlight studies published during 2020 related to CF pulmonary disease, infection, treatment, and diagnostics.

Patient characteristics associated with complications during neonatal intubations

INTRODUCTION

Complications of neonatal intubation are known to be increased with emergent intubations, increased number of attempts, unstable hemodynamics, or ventilation failure; and decreased with use of paralytic medication and videolaryngoscopy. Patient characteristics associated with complications are not well understood.

DESIGN/METHODS

A retrospective cohort study was performed of neonates who underwent intubation between January 2017 and June 2019. Patient characteristics of infants with and without complications were compared. Complications included common adverse events and abnormal vital sign changes occurring during intubation.

RESULTS

A total of 467 intubation encounters in 352 infants were included with median gestational age (GA) at birth of 29 weeks, postmenstrual age (PMA) 33 weeks at intubation, and median weight 1795 g. 41.5% of infants had complications and 58.5% of infants did not. Infants with complications compared to infants without had a median FiO₂ of 0.50 versus 0.45 (p = .183), median GA at birth of 29 versus 31 weeks (p < .001), median PMA of 32 weeks versus 33.0 weeks (p = .352), median weight of 1540 g versus 1970g (p = .091), and median chronological age of 3 days versus 1 day (p = .001). Generalized Estimating Equations controlling for administration of paralytic indicated decreased complications in infants ≤21.5 days in chronological age (OR, 0.45; 95% CI, 0.30-0.69) and increased complications in infants ≤1565 g (OR, 1.52; 95% CI, 1.04-2.23).

CONCLUSION

Patient characteristics associated with an increased rate of complications included chronological age and weight. Further study is needed to reduce complications.

Telemedicine in children with medical complexity on home ventilation during the COVID-19 pandemic

Children with medical complexity (CMC) are patients with one or more complex chronic conditions dependent on medical technologies. In our unit (Pediatric Pulmonology and Respiratory Intermediate Care Unit, Department of Pediatrics, "Bambino Gesù" Children's Hospital and Research Institute), we regularly follow-up CMC patients, particularly children on long-term, invasive (IMV) or noninvasive (NIV), ventilation. Children suffering from chronic diseases and with medical complexity have lost the possibility to go to the hospital during the COVID-19 pandemic. The aim of this article is to describe our experience with telemedicine (teleconsultation [TC] and telemonitoring of ventilator [TM]) in CMC on ventilation. We presented 21 children on long-term ventilation (NIV or IMV) whose planned hospital admission was postponed due to lockdown. A total of 12 healthcare problems were detected during scheduled TCs. Only one problem was not solved by our remote intervention. Specifically, TM has allowed us to change the ventilator parameters and to monitor patients on ventilation remotely. In conclusion, the use of telemedicine in CMC ventilated patients resulted in a feasible tool to avoid in-person visits during the pandemic.

Built-in software in children on long-term ventilation in real life practice

Information gathered with built-in software (BIS) on new ventilators allow clinicians to access long-term noninvasive ventilation (LTNIV) data. Nevertheless, few evidence are available in literature that highlight potential strengths and disadvantages of using BIS in pediatrics. We aim to evaluate the use of BIS in a cohort of 90 children on LTNIV in our unit, focusing mainly on adherence, air leaks, and residual sleep events. We found that caregivers' perception of ventilator use is independent from objective adherence (P = .137). Furthermore, we failed to find any predictors of adherence. As regards air leaks, we found that pre-scholars' (0-6 years old) total air leaks are lower than teenagers' (more than 12 years old) (P < .05). Multiple regressive analysis showed that age at the beginning of therapy is a predictor of total air leaks: prescholars are associated with lower values (P < .05), while scholars (6-12 years old) are associated with higher values (P < .05). Finally, we explored the validity of BIS automatic scoring of sleep events (AHI_BIS ) as compared with the manual scoring of polygraphy (AHI_PG ). AHI_BIS is within a range of 3.98 from AHI_PG in 95% of cases, with a 64% of sensitivity and a 67% of specificity in identifying a pathological state. The disagreement between the two methods seems to increase for high AHI values. In conclusion, data gathered by BIS are a useful support tool for the clinician in assessing the course of LTNIV. However, clinicians must be aware of the several limitations of built-in software, especially in pediatrics.

Prenatal exposure to VOCs and NOx and lung function in preschoolers

BACKGROUND

Several studies have shown that exposure to air pollutants affects lung growth and development and can result in poor respiratory health in early life.

METHODS

We included a subsample of 772 Mexican preschoolers whose mothers participated in a Prenatal Omega-3 fatty acid Supplements, GRowth, And Development birth cohort study with the aim to evaluate the impact of prenatal exposure to volatile organic compounds and nitrogen oxides on lung function measured by oscillation tests. The preschoolers were followed until 5 years of age. Anthropometric measurements and forced oscillation tests were performed at 36, 48, and 60 months of age. Information on sociodemographic and health characteristics was obtained during follow up. Prenatal exposure to volatile organic compounds and nitrogen oxides was evaluated using a land use regression models and the association between them was tested using a lineal regression and longitudinal linear mixed effect models adjusting for potential confounders.

RESULTS

Overall, the mean (standard deviation) of the measurements of respiratory system resistance and respiratory system reactance at 6, 8, and 10 Hz during the follow-up period was 11.3 (2.4), 11.1 (2.4), 10.3 (2.2) and -5.2 (1.6), -4.8 (1.7), and -4.6 hPa s L^-1 (1.6), respectively. We found a significantly positive association between respiratory resistance (β_Rrs6  = 0.011; 95%CI: 0.001, 0.023) (P < .05) and prenatal exposure to nitrogen dioxide and a marginally negatively association between respiratory reactance (β_Xrs6  = -11.40 95%CI: -25.26, 1.17 and β_Xrs8  = -11.91 95%CI: -26.51, 1.43) (P = .07) and prenatal exposure to xylene.

CONCLUSION

Prenatal exposure to air pollutants was significantly associated with the alteration of lung function measured by oscillation tests in these preschool children.

Opportunities on the road to value-based payment for children with chronic respiratory disease

The transition from a fee-for-service payment system to value-based payment system gained momentum in the US in 2010 with the passage of the Affordable Care Act and continues to progress rapidly. Market research estimates that value-based payment models will surpass fee-for-service by 2020. This change offers both great opportunity and great risk to the medical care of the heterogeneous populations of children with chronic respiratory disease. The fee-for-service model has driven the emergence of a healthcare delivery infrastructure markedly misaligned with the medical needs of children with chronic respiratory disease. A change to value-based payment models offers the opportunity to create systems better aligned with the complex and varied care needs of these children. However, rapid change without input from the relevant stakeholders could yield an infrastructure even more misaligned with the needs of children with chronic respiratory disease than the current one and threaten access to high quality medical care for these populations. Through the lens offered by three fictional case studies, this review: (1) illustrates current and evolving payment models; (2) describes limitations of these payment models; and (3) suggests a novel way to envision and evaluate value-based payment models for children with chronic respiratory disease.

Accuracy of oscillatory pressure measured by mechanical ventilators during high frequency oscillatory ventilation in newborns

BACKGROUND

Oscillatory pressure (ΔP) measurement during high frequency oscillatory ventilation (HFOV) is technically challenging and influenced by all the components of the measurement system.

OBJECTIVES

To evaluate the differences between the ΔP delivered at the inlet of the endotracheal tube and those displayed by commercial neonatal mechanical ventilators and monitoring devices and to characterize how the ventilator circuit and the flowmeter proximal to the patient affect these differences.

METHODS

Six devices were evaluated while ventilating three mechanical analogues representing the newborn respiratory system in different disease states. ΔP measured at different points of the ventilator circuit were compared.

RESULTS

ΔP accuracy is highly variable and decreases with increasing oscillation frequency and amplitude, independently of the mean airway pressure. At 15 Hz, a ΔP displayed by ventilators of 40 cmH₂ O resulted in a ΔP effectively delivered at the tracheal tube ranging from 22 to 49 cmH₂ O, depending on the ventilator model, the ventilator circuit, and the patient condition. At these settings, the errors exclusively due to the ventilator circuit and the presence of the flowmeter ranged from 6 to 9 cmH₂ O and from 1 to 6 cmH₂ O, respectively.

CONCLUSIONS

The ventilator model, the breathing circuit, the flowmeter, and the patient condition severely impacts ΔP measurement accuracy during HFOV, leading to highly variable performances. This prevents the possibility of using the ΔP required to normalize gas exchange as an indicator of patients' condition, complicates comparison of ventilators performances, and adds a significant element of complexity in clinical management of HFOV.

The highs and lows of wheezing: A review of the most popular adventitious lung sound

Wheezing is the most widely reported adventitious lung sound in the English language. It is recognized by health professionals as well as by lay people, although often with a different meaning. Wheezing is an indicator of airway obstruction and therefore of interest particularly for the assessment of young children and in other situations where objective documentation of lung function is not generally available. This review summarizes our current understanding of mechanisms producing wheeze, its subjective perception and description, its objective measurement, and visualization, and its relevance in clinical practice.

Transesophageal bronchoscopic ultrasound-guided fine-needle aspiration (EUS-B-FNA)-Pushing the boundaries in the diagnosis

Isolated mediastinal adenopathy is a diagnostic challenge in the paediatric population, often requiring invasive surgical procedures for diagnosis. We describe a novel minimally invasive modality in a 20 month toddler-transesophageal bronchoscopic ultrasound-guided fine-needle aspiration (EUS-B-FNA). This is the youngest reported use of this modality, highlighting feasibility, technical issues, safety, and rapid diagnosis leading to expedited treatment.

Pediatric Respiratory Support Technology and Practices: A Global Survey

Objective: This global survey aimed to assess the current respiratory support capabilities for children with hypoxemia and respiratory failure in different economic settings. Methods: An online, anonymous survey of medical providers with experience in managing pediatric acute respiratory illness was distributed electronically to members of the World Federation of Pediatric Intensive and Critical Care Society, and other critical care websites for 3 months. Results: The survey was completed by 295 participants from 64 countries, including 28 High-Income (HIC) and 36 Low- and Middle-Income Countries (LMIC). Most respondents (≥84%) worked in urban tertiary care centers. For managing acute respiratory failure, endotracheal intubation with mechanical ventilation was the most commonly reported form of respiratory support (≥94% in LMIC and HIC). Continuous Positive Airway Pressure (CPAP) was the most commonly reported form of non-invasive positive pressure support (≥86% in LMIC and HIC). Bubble-CPAP was used by 36% HIC and 39% LMIC participants. ECMO for acute respiratory failure was reported by 45% of HIC participants, compared to 34% of LMIC. Oxygen, air, gas humidifiers, breathing circuits, patient interfaces, and oxygen saturation monitoring appear widely available. Reported ICU patient to health care provider ratios were higher in LMIC compared to HIC. The frequency of respiratory assessments was hourly in HIC, compared to every 2–4 h in LMIC. Conclusions: This survey indicates many apparent similarities in the presence of respiratory support systems in urban care centers globally, but system quality, quantity, and functionality were not established by this survey. LMIC ICUs appear to have higher patient to medical staff ratios, with decreased patient monitoring frequencies, suggesting patient safety should be a focus during the introduction of new respiratory support devices and practices.

Domiciliary noninvasive positive airway pressure therapy in children

There has been a dramatic increase in the past few decades in the number of children receiving noninvasive positive airway pressure (PAP) therapy at home. Although PAP therapy was first prescribed for children with obstructive sleep apnea, the indications have rapidly widened to include treatment for central hypoventilation syndromes, neuromuscular and chest wall disorders as well as primary respiratory diseases. Given the rapidly expanding use of PAP therapy in children, pediatric pulmonologists need to be familiar with the indications, technical and safety considerations as well as potential complications and challenges that may arise when caring for children using PAP therapy. This review article covers the definition of PAP therapy, modes, interfaces, devices, indications, contraindications, suggested settings, complications as well as the factors influencing the adherence.