1
|
Winer JC, Richardson T, Berg KJ, Berry J, Chang PW, Etinger V, Hall M, Kim G, Meneses Paz JC, Treasure JD, Aronson PL. Effect Modifiers of the Association of High-Flow Nasal Cannula and Bronchiolitis Length of Stay. Hosp Pediatr 2023; 13:1018-1027. [PMID: 37795554 PMCID: PMC10593863 DOI: 10.1542/hpeds.2023-007295] [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] [Indexed: 10/06/2023]
Abstract
BACKGROUND AND OBJECTIVES High-flow nasal cannula (HFNC) therapy for hospitalized children with bronchiolitis is associated with a longer length of stay (LOS) when used outside of the ICU. We sought to explore the association between HFNC and LOS to identify if demographic and clinical factors may modify the effect of HFNC usage on LOS. METHODS In this multicenter retrospective cohort study, we used a combination of hospital records and the Pediatric Health Information System. We included encounters from September 1, 2018 to March 31, 2020 for patients <2 years old diagnosed with bronchiolitis. Multivariable Poisson regression was performed for the association of LOS with measured covariates, including fixed main effects and interaction terms between HFNC and other factors. RESULTS Of 8060 included patients, 2179 (27.0%) received HFNC during admission. Age group, weight, complex chronic condition, initial tachypnea, initial desaturation, and ICU services were significantly associated with LOS. The effect of HFNC on LOS differed among hospitals (P < .001), with the estimated increase in LOS ranging from 32% to 139%. The effect of HFNC on LOS was modified by age group, initial desaturation, and ICU services, with 1- to 6-month-old infants, patients without initial desaturation, and patients without ICU services having the highest association between HFNC and LOS, respectively. CONCLUSIONS We identified multiple potential effect modifiers for the relationship between HFNC and LOS. The authors of future prospective studies should investigate the effect of HFNC usage on LOS in non-ICU patients without documented desaturation.
Collapse
Affiliation(s)
- Jeffrey C Winer
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Kathleen J Berg
- Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
- University of Kansas School of Medicine, Kansas City, Kansas
| | - Jay Berry
- Complex Care, Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Pearl W Chang
- Seattle Children's Hospital, University of Washington, Seattle, Washington
| | | | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Grace Kim
- Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | - Jennifer D Treasure
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati Ohio
| | | |
Collapse
|
2
|
Maue DK, Cater DT, Rogerson CM, Ealy A, Tori AJ, Abu-Sultaneh S. Outcomes of a respiratory therapist driven high flow nasal cannula management protocol for pediatric critical asthma patients. Pediatr Pulmonol 2023; 58:2881-2888. [PMID: 37606224 DOI: 10.1002/ppul.26606] [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: 05/11/2023] [Revised: 07/04/2023] [Accepted: 07/12/2023] [Indexed: 08/23/2023]
Abstract
INTRODUCTION This study aimed to determine if a respiratory therapist (RT)-driven high flow nasal cannula (HFNC) protocol could decrease duration of HFNC use, pediatric intensive care unit (PICU) and hospital length of stay (LOS), and duration of continuous albuterol use in pediatric patients with critical asthma. METHODS This was a quality improvement project performed at a quaternary academic PICU. Patients admitted to the PICU between 2 and 18 years of age with a diagnosis of asthma requiring continuous albuterol and HFNC were included. Implementation of an RT-driven HFNC protocol [Plan-Do-Study-Act (PDSA) 1] occurred in October 2017. Additional interventions included weaning continuous albuterol and HFNC simultaneously (PDSA 2; March 2019), adjusting HFNC wean rate (PDSA 3; July 2020), and a HFNC holiday (PDSA 4; October 2021). HFNC duration was the primary outcome. Secondary outcomes included LOS data and continuous albuterol duration. Noninvasive ventilation (NIV), invasive mechanical ventilation (IMV), and 7-day PICU and hospital readmission rates were used as balancing measures. RESULTS A total of 410 patients were included. Patient demographics and adjunct therapy use did not differ among the groups. After PDSA 2, mean HFNC duration decreased (26.8-18.1 h). Mean PICU LOS decreased (41-31.8 h). Mean hospital LOS also decreased (86.5-68 h). These outcomes remained stable during PDSA 3 and 4. Continuous albuterol duration and NIV use were unchanged, while IMV use decreased. CONCLUSIONS An RT-driven HFNC protocol led to decreased length of HFNC and PICU and hospital LOS for pediatric patients with critical asthma without an increase in adverse events.
Collapse
Affiliation(s)
- Danielle K Maue
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Daniel T Cater
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Colin M Rogerson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Aimee Ealy
- Department of Respiratory Care Services, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, USA
| | - Alvaro J Tori
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Samer Abu-Sultaneh
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| |
Collapse
|
3
|
Abdelbaky AM, Elmasry WG, Awad AH, Khan S, Jarrahi M. The Impact of High-Flow Nasal Cannula Therapy on Acute Respiratory Distress Syndrome Patients: A Systematic Review. Cureus 2023; 15:e41219. [PMID: 37397646 PMCID: PMC10313388 DOI: 10.7759/cureus.41219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2023] [Indexed: 07/04/2023] Open
Abstract
High-flow nasal cannula (HFNC) is a novel oxygenation approach in the management of acute respiratory distress syndrome (ARDS). This systematic review was focused on evaluating current evidence concerning the efficacy of HFNC in ARDS and its comparison with standard treatment approaches. For this review, a systematic search was undertaken in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Web of Science, Cochrane Library, and Google Scholar to identify relevant studies. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. All those studies that investigated the impact of HFNC on ARDS patients and were published in the English language were included. The literature search from all databases provided 6157 potentially relevant articles from PubMed (n = 1105), CINAHL (n = 808), Web of Science (n = 811), Embase (n = 2503), Cochrane database (n = 930), and Google Scholar (n = 46). After the exclusion of studies that did not fulfill the criteria, 18 studies were shortlisted for the scope of this systematic review. Among the included studies, five focused on HFNC's impact on COVID-19-related ARDS, whereas 13 studies focused on HFNC's impact on ARDS patients. Most studies demonstrated the efficacy of HFNC in managing ARDS, with some studies showing comparable efficacy and higher safety compared to noninvasive ventilation (NIV). This systematic review highlights the potential benefits of HFNC in ARDS management. The findings show that HFNC is effective in reducing the respiratory distress symptoms, the incidence of invasive ventilation, and the adverse events associated with ARDS. These findings can help clinical decision-making processes and contribute to the evidence base for optimal ARDS management strategies.
Collapse
Affiliation(s)
- Ahmed M Abdelbaky
- Intensive Care Unit, Dubai Academic Health Corporation - Rashid Hospital, Dubai, ARE
| | - Wael G Elmasry
- Intensive Care Unit, Dubai Academic Health Corporation - Rashid Hospital, Dubai, ARE
| | - Ahmed H Awad
- Intensive Care Unit, Dubai Academic Health Corporation - Rashid Hospital, Dubai, ARE
| | - Sarrosh Khan
- Internal Medicine, Dubai Academic Health Corporation - Rashid Hospital, Dubai, ARE
| | - Maryam Jarrahi
- Internal Medicine, Dubai Academic Health Corporation - Rashid Hospital, Dubai, ARE
| |
Collapse
|
4
|
Cavallaro S, Easter J. Updates in pediatric emergency medicine for 2022. Am J Emerg Med 2023; 68:73-83. [PMID: 36958093 DOI: 10.1016/j.ajem.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 03/11/2023] Open
Abstract
As a relatively new field, there has been a recent explosion in evidence around the management of children in the emergency department (ED). This review highlights 10 articles published in the last year providing evidence that is germane to the care of children by emergency medicine (EM) physicians. There is a focus on high prevalence conditions, such as fever and trauma, as well as interventions that can improve mortality, such as cardiopulmonary resuscitation and massive transfusion.
Collapse
Affiliation(s)
- Sarah Cavallaro
- Division of Emergency Medicine, Children's Hospital of Boston, Boston, MA 02115, United States of America
| | - Joshua Easter
- Department of Emergency Medicine, University of Virginia, 200 Jeanette Lancaster Way, Charlottesville, VA 22903, United States of America.
| |
Collapse
|
5
|
Commentary on the First-Line Support for Assistance in Breathing in Children Trials on Noninvasive Respiratory Support: Taking a Closer Look. Pediatr Crit Care Med 2022; 23:1084-1088. [PMID: 36305663 DOI: 10.1097/pcc.0000000000003096] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Noninvasive respiratory support modalities such as high-flow nasal cannula (HFNC) therapy and continuous positive airway pressure (CPAP) are used frequently in pediatric critical care to support acutely ill children with respiratory failure (step-up management) and children following extubation (step-down management). Although there are several observational studies and database analyses comparing the efficacy of HFNC and CPAP, and a few small randomized clinical trials (RCTs), until recently, there were no large RCTs comparing the two modalities in a mixed group of critically ill children. In the first half of 2022, results from the First-Line Support for Assistance in Breathing in Children (FIRST-ABC) trials were published; these comprised a master protocol of two trials: one in acutely ill children (step-up RCT) and one in extubated children (step-down RCT). Each of these pragmatic trials randomized 600 children to either HFNC or CPAP when the treating clinician decided that noninvasive respiratory support beyond standard oxygen therapy was required. The primary outcome was time to liberation from all forms of respiratory support (invasive and noninvasive), excluding supplemental oxygen. The FIRST-ABC trials represent a significant advance in the field of noninvasive respiratory support, which has traditionally been evidence-poor and associated with considerable variability in clinical practice. In this article, we provide an overview of how the FIRST-ABC trials were conceived and conducted, our view on the results, and how the trial findings have changed our clinical practice.
Collapse
|
6
|
Commentary on High-Flow Nasal Cannula and Continuous Positive Airway Pressure Practices After the First-Line Support for Assistance in Breathing in Children Trials. Pediatr Crit Care Med 2022; 23:1076-1083. [PMID: 36250746 DOI: 10.1097/pcc.0000000000003097] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Continuous positive airway pressure (CPAP) and heated humidified high-flow nasal cannula (HFNC) are commonly used to treat children admitted to the PICU who require more respiratory support than simple oxygen therapy. Much has been published on these two treatment modalities over the past decade, both in Pediatric Critical Care Medicine (PCCM ) and elsewhere. The majority of these studies are observational analyses of clinical, administrative, or quality improvement datasets and, therefore, are only able to establish associations between exposure to treatment and outcomes, not causation. None of the initial randomized clinical trials comparing HFNC and CPAP were definitive due to their relatively small sample sizes with insufficient power for meaningful clinical outcomes (e.g., escalation to bilevel noninvasive ventilation or intubation, duration of PICU-level respiratory support, mortality) and often yielded ambiguous findings or conflicting results. The recent publication of the First-Line Support for Assistance in Breathing in Children (FIRST-ABC) trials represented a major step toward understanding the role of CPAP and HFNC use in critically ill children. These large, pragmatic, randomized clinical trials examined the efficacy of CPAP and HFNC either for "step up" (i.e., escalation in respiratory support) during acute respiratory deterioration or for "step down" (i.e., postextubation need for respiratory support) management. This narrative review examines the body of evidence on HFNC published in PCCM , contextualizes the findings of randomized clinical trials of CPAP and HFNC up to and including the FIRST-ABC trials, provides guidance to PICU clinicians on how to implement the literature in current practice, and discusses remaining knowledge gaps and future research priorities.
Collapse
|
7
|
Sandal O, Ceylan G, Topal S, Hepduman P, Colak M, Novotni D, Soydan E, Karaarslan U, Atakul G, Schultz MJ, Ağın H. Closed–loop oxygen control improves oxygenation in pediatric patients under high–flow nasal oxygen—A randomized crossover study. Front Med (Lausanne) 2022; 9:1046902. [DOI: 10.3389/fmed.2022.1046902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 10/26/2022] [Indexed: 11/17/2022] Open
Abstract
BackgroundWe assessed the effect of a closed–loop oxygen control system in pediatric patients receiving high–flow nasal oxygen therapy (HFNO).MethodsA multicentre, single–blinded, randomized, and cross–over study. Patients aged between 1 month and 18 years of age receiving HFNO for acute hypoxemic respiratory failure (AHRF) were randomly assigned to start with a 2–h period of closed–loop oxygen control or a 2–h period of manual oxygen titrations, after which the patient switched to the alternative therapy. The endpoints were the percentage of time spent in predefined SpO2 ranges (primary), FiO2, SpO2/FiO2, and the number of manual adjustments.FindingsWe included 23 patients, aged a median of 18 (3–26) months. Patients spent more time in a predefined optimal SpO2 range when the closed–loop oxygen controller was activated compared to manual oxygen titrations [91⋅3% (IQR 78⋅4–95⋅1%) vs. 63⋅0% (IQR 44⋅4–70⋅7%)], mean difference [28⋅2% (95%–CI 20⋅6–37⋅8%); P < 0.001]. Median FiO2 was lower [33⋅3% (IQR 26⋅6–44⋅6%) vs. 42⋅6% (IQR 33⋅6–49⋅9%); P = 0.07], but median SpO2/FiO2 was higher [289 (IQR 207–348) vs. 194 (IQR 98–317); P = 0.023] with closed–loop oxygen control. The median number of manual adjustments was lower with closed–loop oxygen control [0⋅0 (IQR 0⋅0–0⋅0) vs. 0⋅5 (IQR 0⋅0–1⋅0); P < 0.001].ConclusionClosed-loop oxygen control improves oxygenation therapy in pediatric patients receiving HFNO for AHRF and potentially leads to more efficient oxygen use. It reduces the number of manual adjustments, which may translate into decreased workloads of healthcare providers.Clinical trial registration[www.ClinicalTrials.gov], identifier [NCT 05032365].
Collapse
|
8
|
Ramnarayan P, Richards-Belle A, Drikite L, Saull M, Orzechowska I, Darnell R, Sadique Z, Lester J, Morris KP, Tume LN, Davis PJ, Peters MJ, Feltbower RG, Grieve R, Thomas K, Mouncey PR, Harrison DA, Rowan KM. Effect of High-Flow Nasal Cannula Therapy vs Continuous Positive Airway Pressure Therapy on Liberation From Respiratory Support in Acutely Ill Children Admitted to Pediatric Critical Care Units: A Randomized Clinical Trial. JAMA 2022; 328:162-172. [PMID: 35707984 PMCID: PMC9204623 DOI: 10.1001/jama.2022.9615] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
IMPORTANCE The optimal first-line mode of noninvasive respiratory support for acutely ill children is not known. OBJECTIVE To evaluate the noninferiority of high-flow nasal cannula therapy (HFNC) as the first-line mode of noninvasive respiratory support for acute illness, compared with continuous positive airway pressure (CPAP), for time to liberation from all forms of respiratory support. DESIGN, SETTING, AND PARTICIPANTS Pragmatic, multicenter, randomized noninferiority clinical trial conducted in 24 pediatric critical care units in the United Kingdom among 600 acutely ill children aged 0 to 15 years who were clinically assessed to require noninvasive respiratory support, recruited between August 2019 and November 2021, with last follow-up completed in March 2022. INTERVENTIONS Patients were randomized 1:1 to commence either HFNC at a flow rate based on patient weight (n = 301) or CPAP of 7 to 8 cm H2O (n = 299). MAIN OUTCOMES AND MEASURES The primary outcome was time from randomization to liberation from respiratory support, defined as the start of a 48-hour period during which a participant was free from all forms of respiratory support (invasive or noninvasive), assessed against a noninferiority margin of an adjusted hazard ratio of 0.75. Seven secondary outcomes were assessed, including mortality at critical care unit discharge, intubation within 48 hours, and use of sedation. RESULTS Of the 600 randomized children, consent was not obtained for 5 (HFNC: 1; CPAP: 4) and respiratory support was not started in 22 (HFNC: 5; CPAP: 17); 573 children (HFNC: 295; CPAP: 278) were included in the primary analysis (median age, 9 months; 226 girls [39%]). The median time to liberation in the HFNC group was 52.9 hours (95% CI, 46.0-60.9 hours) vs 47.9 hours (95% CI, 40.5-55.7 hours) in the CPAP group (absolute difference, 5.0 hours [95% CI -10.1 to 17.4 hours]; adjusted hazard ratio 1.03 [1-sided 97.5% CI, 0.86-∞]). This met the criterion for noninferiority. Of the 7 prespecified secondary outcomes, 3 were significantly lower in the HFNC group: use of sedation (27.7% vs 37%; adjusted odds ratio, 0.59 [95% CI, 0.39-0.88]); mean duration of critical care stay (5 days vs 7.4 days; adjusted mean difference, -3 days [95% CI, -5.1 to -1 days]); and mean duration of acute hospital stay (13.8 days vs 19.5 days; adjusted mean difference, -7.6 days [95% CI, -13.2 to -1.9 days]). The most common adverse event was nasal trauma (HFNC: 6/295 [2.0%]; CPAP: 18/278 [6.5%]). CONCLUSIONS AND RELEVANCE Among acutely ill children clinically assessed to require noninvasive respiratory support in a pediatric critical care unit, HFNC compared with CPAP met the criterion for noninferiority for time to liberation from respiratory support. TRIAL REGISTRATION ISRCTN.org Identifier: ISRCTN60048867.
Collapse
Affiliation(s)
- Padmanabhan Ramnarayan
- Section of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, England
- Children’s Acute Transport Service, Great Ormond Street Hospital for Children NHS Foundation Trust, London, England
| | - Alvin Richards-Belle
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Laura Drikite
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Michelle Saull
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Izabella Orzechowska
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Robert Darnell
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, England
| | | | - Kevin P. Morris
- Birmingham Children’s Hospital, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, England
- Institute of Applied Health Research, University of Birmingham, Birmingham, England
| | - Lyvonne N. Tume
- School of Health and Society, University of Salford, Salford, England
| | - Peter J. Davis
- Paediatric Intensive Care Unit, Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, England
| | - Mark J. Peters
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, England
- University College London Great Ormond Street Institute of Child Health, London, England
| | - Richard G. Feltbower
- Leeds Institute for Data Analytics, School of Medicine, University of Leeds, Leeds, England
| | - Richard Grieve
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, England
| | - Karen Thomas
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Paul R. Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - David A. Harrison
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Kathryn M. Rowan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| |
Collapse
|
9
|
Udurgucu M, Albayrak H, Kinik Kaya HE, Yener N. Comparison of Two Weaning Methods from Heated Humidified High-Flow Nasal Cannula Therapy in Pediatric Intensive Care Unit. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2022; 35:79-85. [PMID: 35587212 PMCID: PMC9247675 DOI: 10.1089/ped.2021.0229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 04/04/2022] [Indexed: 06/03/2023]
Abstract
Background and Objective: Although high-flow nasal cannula (HFNC) is widely used in children, there is no consensus on the methods for starting, maintenance, and weaning. The aim of this study was to compare weaning methods in children. Methods: The study included all patients in pediatric intensive care unit (PICU) who were started on HFNC treatment. The respiratory assessment score was used in the decisions for starting, continuing, and weaning from HFNC. The patients who responded and for whom weaning was planned were randomized by month into 2 groups as directly weaned from HFNC and weaned by reducing the flow. Success rates, treatment, and length of stay (LOS) in weaning methods were compared. Results: Of the 145 patients initially included in the study, 32 (22%) were excluded, and analysis was made of 113 patients. Successful weaning from HFNC was obtained in 76.9% of the patients, in 82.1% of flow weaning, and 73.6% of direct weaning, with no statistically significant difference determined between the groups (P = 0.286). The median duration of HFNC and the median LOS in PICU were determined to be statistically significantly shorter in direct weaning than in flow weaning [36 h interquartile range (IQR) 24-48 h] versus 60 h (IQR 60-72 h), P < 0.001 and 6 days (4-14 days) versus 9.5 days (5.25-20.75 days, P = 0.043, respectively). Conclusion: In patients who responded to HFNC in PICU, the responses to direct weaning and flow reduction were seen to be similar. In patients directly weaned off, both the HFNC duration and LOS in PICU were significantly shorter.
Collapse
Affiliation(s)
- Muhammed Udurgucu
- Division of Pediatric Critical Care, Ondokuz Mayıs University School of Medicine, Samsun, Turkey
| | - Hatice Albayrak
- Division of Pediatric Critical Care, Ondokuz Mayıs University School of Medicine, Samsun, Turkey
| | - Hatice Elif Kinik Kaya
- Division of Pediatric Critical Care, Ondokuz Mayıs University School of Medicine, Samsun, Turkey
| | - Nazik Yener
- Division of Pediatric Critical Care, Ondokuz Mayıs University School of Medicine, Samsun, Turkey
| |
Collapse
|
10
|
Ramnarayan P, Richards-Belle A, Drikite L, Saull M, Orzechowska I, Darnell R, Sadique Z, Lester J, Morris KP, Tume LN, Davis PJ, Peters MJ, Feltbower RG, Grieve R, Thomas K, Mouncey PR, Harrison DA, Rowan KM. Effect of High-Flow Nasal Cannula Therapy vs Continuous Positive Airway Pressure Following Extubation on Liberation From Respiratory Support in Critically Ill Children: A Randomized Clinical Trial. JAMA 2022; 327:1555-1565. [PMID: 35390113 PMCID: PMC8990361 DOI: 10.1001/jama.2022.3367] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
IMPORTANCE The optimal first-line mode of noninvasive respiratory support following extubation of critically ill children is not known. OBJECTIVE To evaluate the noninferiority of high-flow nasal cannula (HFNC) therapy as the first-line mode of noninvasive respiratory support following extubation, compared with continuous positive airway pressure (CPAP), on time to liberation from respiratory support. DESIGN, SETTING, AND PARTICIPANTS This was a pragmatic, multicenter, randomized, noninferiority trial conducted at 22 pediatric intensive care units in the United Kingdom. Six hundred children aged 0 to 15 years clinically assessed to require noninvasive respiratory support within 72 hours of extubation were recruited between August 8, 2019, and May 18, 2020, with last follow-up completed on November 22, 2020. INTERVENTIONS Patients were randomized 1:1 to start either HFNC at a flow rate based on patient weight (n = 299) or CPAP of 7 to 8 cm H2O (n = 301). MAIN OUTCOMES AND MEASURES The primary outcome was time from randomization to liberation from respiratory support, defined as the start of a 48-hour period during which the child was free from all forms of respiratory support (invasive or noninvasive), assessed against a noninferiority margin of an adjusted hazard ratio (HR) of 0.75. There were 6 secondary outcomes, including mortality at day 180 and reintubation within 48 hours. RESULTS Of the 600 children who were randomized, 553 children (HFNC, 281; CPAP, 272) were included in the primary analysis (median age, 3 months; 241 girls [44%]). HFNC failed to meet noninferiority, with a median time to liberation of 50.5 hours (95% CI, 43.0-67.9) vs 42.9 hours (95% CI, 30.5-48.2) for CPAP (adjusted HR, 0.83; 1-sided 97.5% CI, 0.70-∞). Similar results were seen across prespecified subgroups. Of the 6 prespecified secondary outcomes, 5 showed no significant difference, including the rate of reintubation within 48 hours (13.3% for HFNC vs 11.5 % for CPAP). Mortality at day 180 was significantly higher for HFNC (5.6% vs 2.4% for CPAP; adjusted odds ratio, 3.07 [95% CI, 1.1-8.8]). The most common adverse events were abdominal distension (HFNC: 8/281 [2.8%] vs CPAP: 7/272 [2.6%]) and nasal/facial trauma (HFNC: 14/281 [5.0%] vs CPAP: 15/272 [5.5%]). CONCLUSIONS AND RELEVANCE Among critically ill children requiring noninvasive respiratory support following extubation, HFNC compared with CPAP following extubation failed to meet the criterion for noninferiority for time to liberation from respiratory support. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN60048867.
Collapse
Affiliation(s)
- Padmanabhan Ramnarayan
- Section of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, United Kingdom
- Children’s Acute Transport Service, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Alvin Richards-Belle
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Laura Drikite
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Michelle Saull
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Izabella Orzechowska
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Robert Darnell
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Kevin P. Morris
- Birmingham Children’s Hospital, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Lyvonne N. Tume
- School of Health & Society, University of Salford, Salford, United Kingdom
| | - Peter J. Davis
- Paediatric Intensive Care Unit, Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Mark J. Peters
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, United Kingdom
- University College London Great Ormond St Institute of Child Health, London, United Kingdom
| | - Richard G. Feltbower
- Leeds Institute for Data Analytics, School of Medicine, University of Leeds, Leeds, United Kingdom
| | - Richard Grieve
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Karen Thomas
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Paul R. Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - David A. Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Kathryn M. Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| |
Collapse
|
11
|
Lindell RB, Fitzgerald JC, Rowan CM, Flori HR, Di Nardo M, Napolitano N, Traynor DM, Lenz KB, Emeriaud G, Jeyapalan A, Nishisaki A. The Use and Duration of Preintubation Respiratory Support Is Associated With Increased Mortality in Immunocompromised Children With Acute Respiratory Failure. Crit Care Med 2022; 50:1127-1137. [PMID: 35275593 PMCID: PMC9707852 DOI: 10.1097/ccm.0000000000005535] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine the association between preintubation respiratory support and outcomes in patients with acute respiratory failure and to determine the impact of immunocompromised (IC) diagnoses on outcomes after adjustment for illness severity. DESIGN Retrospective multicenter cohort study. SETTING Eighty-two centers in the Virtual Pediatric Systems database. PATIENTS Children 1 month to 17 years old intubated in the PICU who received invasive mechanical ventilation (IMV) for greater than or equal to 24 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS High-flow nasal cannula (HFNC) or noninvasive positive-pressure ventilation (NIPPV) or both were used prior to intubation in 1,825 (34%) of 5,348 PICU intubations across 82 centers. When stratified by IC status, 50% of patients had no IC diagnosis, whereas 41% were IC without prior hematopoietic cell transplant (HCT) and 9% had prior HCT. Compared with patients intubated without prior support, preintubation exposure to HFNC (adjusted odds ratio [aOR], 1.33; 95% CI, 1.10-1.62) or NIPPV (aOR, 1.44; 95% CI, 1.20-1.74) was associated with increased odds of PICU mortality. Within subgroups of IC status, preintubation respiratory support was associated with increased odds of PICU mortality in IC patients (HFNC: aOR, 1.50; 95% CI, 1.11-2.03; NIPPV: aOR, 1.76; 95% CI, 1.31-2.35) and HCT patients (HFNC: aOR, 1.75; 95% CI, 1.07-2.86; NIPPV: aOR, 1.85; 95% CI, 1.12-3.02) compared with IC/HCT patients intubated without prior respiratory support. Preintubation exposure to HFNC/NIPPV was not associated with mortality in patients without an IC diagnosis. Duration of HFNC/NIPPV greater than 6 hours was associated with increased mortality in IC HCT patients (HFNC: aOR, 2.41; 95% CI, 1.05-5.55; NIPPV: aOR, 2.53; 95% CI, 1.04-6.15) and patients compared HCT patients with less than 6-hour HFNC/NIPPV exposure. After adjustment for patient and center characteristics, both preintubation HFNC/NIPPV use (median, 15%; range, 0-63%) and PICU mortality varied by center. CONCLUSIONS In IC pediatric patients, preintubation exposure to HFNC and/or NIPPV is associated with increased odds of PICU mortality, independent of illness severity. Longer duration of exposure to HFNC/NIPPV prior to IMV is associated with increased mortality in HCT patients.
Collapse
Affiliation(s)
- Robert B Lindell
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. Division of Critical Care, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN. Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI. Pediatric Intensive Care Unit, Bambino Gesù, Children's Hospital, IRCCS, Rome, Italy. Department of Respiratory Therapy, Children's Hospital of Philadelphia, Philadelphia, PA. Department of Pediatrics, Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, Montreal, QC. Division of Pediatric Critical Care Medicine, University of Miami Miller School of Medicine, Miami, FL
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Clayton JA, Slain KN, Shein SL, Cheifetz IM. High Flow Nasal Cannula in the Pediatric Intensive Care Unit. Expert Rev Respir Med 2022; 16:409-417. [PMID: 35240901 DOI: 10.1080/17476348.2022.2049761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The use of high flow nasal cannula (HFNC) has become widely used in pediatric intensive care units (PICUs) throughout the world. The rapid adoption has outpaced the number of studies evaluating the safety and efficacy in a variety of pediatric diseases/conditions. AREAS COVERED This scoping review begins with the definition and mechanisms of action of HFNC and then follows with a review of the literature focused on studies performed on critically ill children cared for in the PICU. The Pubmed database was searched with a pediatric filter from the time period 2000 to 2021. EXPERT OPINION The rapid adoption of HFNC in PICUs has largely been driven by changes in institutional practices and small observational studies. There is a lack of adequately powered studies evaluating patient-centered outcomes, such as intubation rates, mortality, PICU and hospital length of stay. Given the wide variability in flow rates and clinical indications, more research is needed to better define effective flow rates for different disease states as well as markers of treatment success and failure. One particular entity that is poorly studied is the use of HFNC in those at risk for developing pediatric acute respiratory distress syndrome (PARDS).
Collapse
Affiliation(s)
- Jason A Clayton
- Division of Pediatric Critical Care Medicine, Rainbow Babies & Children's Hospital, Cleveland, Ohio
| | - Katherine N Slain
- Division of Pediatric Critical Care Medicine, Rainbow Babies & Children's Hospital, Cleveland, Ohio
| | - Steven L Shein
- Division of Pediatric Critical Care Medicine, Rainbow Babies & Children's Hospital, Cleveland, Ohio
| | - Ira M Cheifetz
- Division of Pediatric Cardiac Critical Care Medicine, Rainbow Babies & Children's Hospital, Cleveland, Ohio
| |
Collapse
|
13
|
De-escalation of High-flow Respiratory Support for Children Admitted with Bronchiolitis: A Quality Improvement Initiative. Pediatr Qual Saf 2022; 7:e534. [PMID: 35369406 PMCID: PMC8970083 DOI: 10.1097/pq9.0000000000000534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 11/05/2021] [Indexed: 11/26/2022] Open
Abstract
Bronchiolitis is the most common cause for hospitalization in the first year of life, with hypoxemia and acute respiratory failure as major determinants leading to hospitalization. In addition, the lack of existing guidelines for weaning and discontinuing supplemental oxygen, including high-flow nasal cannula, may contribute to prolonged hospitalization and increased resource utilization.
Collapse
|
14
|
Biggerstaff S, Markham JL, Winer JC, Richardson T, Berg KJ. Impact of High Flow Nasal Cannula on Resource Utilization in Bronchiolitis. Hosp Pediatr 2021:e2021005846. [PMID: 34957495 DOI: 10.1542/hpeds.2021-005846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES High flow nasal cannula (HFNC) is increasingly used for children hospitalized with bronchiolitis. We aimed to validate identification of HFNC use in a national database, then compare resource utilization among children treated with and without HFNC. METHODS In this cross-sectional, multicenter study, we obtained clinical and resource utilization data from the Pediatric Health Information System (PHIS) database for healthy children aged 1 to 24 months admitted for bronchiolitis. We assessed HFNC use based on a combination of billing codes and reviewed charts at 2 hospitals to determine their accuracy. We compared costs, length of stay, and readmissions between the HFNC and no HFNC groups at hospitals utilizing the HFNC codes. RESULTS The PHIS codes demonstrated 90.4% sensitivity and 99.3% specificity to detect HFNC use as verified by chart review at 2 hospitals. However, only 24 of 51 PHIS hospitals used these codes for ≥1% of patients with bronchiolitis. Within those hospitals, children treated with HFNC had greater total costs ($7054 vs $4544; P < .001), greater daily costs ($2922 vs $2613; P < .001), and longer length of stay (57.6 vs 41.6 hours; P < .001). Those treated with HFNC were less likely to be readmitted at 3 and 7 days (P < .001), but by 14 days, readmissions were similar in the 2 groups. CONCLUSIONS Billing codes for HFNC are inconsistently applied across PHIS hospitals; however, among those hospitals that routinely apply these codes, HFNC was associated with more intense resource utilization. Standardization of billing practices for HFNC would allow future study to more broadly describe the value of HFNC.
Collapse
Affiliation(s)
- Scott Biggerstaff
- Department of Pediatrics, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Jessica L Markham
- Department of Pediatrics, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
- Department of Pediatrics, University of Kansas School of Medicine, Kansas City, Kansas
| | - Jeffrey C Winer
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee; and
| | | | - Kathleen J Berg
- Department of Pediatrics, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
- Department of Pediatrics, University of Kansas School of Medicine, Kansas City, Kansas
| |
Collapse
|
15
|
Colleti Júnior J, Kawaguchi A, Araujo ORD, Garros D. Clinical practices related to high-flow nasal cannulas in pediatric critical care in Brazil compared to other countries: a Brazilian survey. Rev Bras Ter Intensiva 2021; 33:384-393. [PMID: 35107549 PMCID: PMC8555393 DOI: 10.5935/0103-507x.20210055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 11/29/2020] [Indexed: 11/20/2022] Open
Abstract
Objetivo Descrever as práticas clínicas atuais relacionadas à
utilização de cânula nasal de alto fluxo por
intensivistas pediátricos brasileiros e compará-las com as de
outros países. Métodos Para o estudo principal, foi administrado um questionário a
intensivistas pediátricos em países das Américas do
Norte e do Sul, Ásia, Europa e Austrália/Nova Zelândia.
Comparou-se a coorte brasileira com coortes dos Estados Unidos,
Canadá, Reino Unido e Índia. Resultados Responderam ao questionário 501 médicos, dos quais 127 eram do
Brasil. Apenas 63,8% dos participantes brasileiros tinham disponibilidade de
cânula nasal de alto fluxo, em contraste com 100% dos participantes
no Reino Unido, no Canadá e nos Estados Unidos. Coube ao
médico responsável a decisão de iniciar a
utilização de uma cânula nasal de alto fluxo segundo
responderam 61,2% dos brasileiros, 95,5% dos localizados no Reino Unido,
96,6% dos participantes dos Estados Unidos, 96,8% dos médicos
canadenses e 84,7% dos participantes da Índia; 62% dos participantes do
Brasil, 96,3% do Reino Unido, 96,6% dos Estados Unidos, 96,8% do
Canadá e 84,7% da Índia relataram que o médico
responsável era quem definia o desmame ou modificava as regulagens da
cânula nasal de alto fluxo. Quando ocorreu falha da cânula
nasal de alto fluxo por desconforto respiratório ou
insuficiência respiratória, 82% dos participantes do Brasil
considerariam uma tentativa com ventilação não invasiva
antes da intubação endotraqueal, em comparação
com 93% do Reino Unido, 88% dos Estados Unidos, 91,5% do Canadá e
76,8% da Índia. Mais intensivistas brasileiros (6,5%) do que do Reino Unido,
Estados Unidos e Índia (1,6% para todos) afirmaram utilizar sedativos com
frequência concomitantemente à cânula nasal de alto
fluxo. Conclusão A disponibilidade de cânulas nasais de alto fluxo no Brasil ainda
não é difundida. Há algumas divergências nas
práticas clínicas entre intensivistas brasileiros e seus
colegas estrangeiros, principalmente nos processos e nas tomadas de
decisão relacionados a iniciar e desmamar o tratamento com
cânula nasal de alto fluxo.
Collapse
Affiliation(s)
- José Colleti Júnior
- Unidade de Terapia Intensiva Pediátrica, Hospital Santa Catarina - São Paulo (SP), Brasil
| | - Atsushi Kawaguchi
- Departamento de Pediatria, Universidade de Montreal, CHU Sainte-Justine - Montreal, QC, Canadá
| | - Orlei Ribeiro de Araujo
- Grupo de Apoio ao Adolescente e à Criança com Câncer, Instituto de Oncologia Pediátrica, Universidade Federal de São Paulo - São Paulo (SP), Brasil
| | - Daniel Garros
- Departamento de Pediatria, Division of Critical Care, Stollery Children's Hospital, University of Alberta - Edmonton, AB, Canadá
| |
Collapse
|
16
|
Pappy G, Aczon M, Wetzel R, Ledbetter D. Predicting High-Flow Nasal Cannula Failure in an ICU Using a Recurrent Neural Network with Transfer Learning and Input Data Perseveration: A Retrospective Analysis (Preprint). JMIR Med Inform 2021; 10:e31760. [PMID: 35238792 PMCID: PMC8931642 DOI: 10.2196/31760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 12/10/2021] [Accepted: 01/03/2022] [Indexed: 12/03/2022] Open
Abstract
Background High flow nasal cannula (HFNC) provides noninvasive respiratory support for children who are critically ill who may tolerate it more readily than other noninvasive ventilation (NIV) techniques such as bilevel positive airway pressure and continuous positive airway pressure. Moreover, HFNC may preclude the need for mechanical ventilation (intubation). Nevertheless, NIV or intubation may ultimately be necessary for certain patients. Timely prediction of HFNC failure can provide an indication for increasing respiratory support. Objective The aim of this study is to develop and compare machine learning (ML) models to predict HFNC failure. Methods A retrospective study was conducted using the Virtual Pediatric Intensive Care Unit database of electronic medical records of patients admitted to a tertiary pediatric intensive care unit between January 2010 and February 2020. Patients aged <19 years, without apnea, and receiving HFNC treatment were included. A long short-term memory (LSTM) model using 517 variables (vital signs, laboratory data, and other clinical parameters) was trained to generate a continuous prediction of HFNC failure, defined as escalation to NIV or intubation within 24 hours of HFNC initiation. For comparison, 7 other models were trained: a logistic regression (LR) using the same 517 variables, another LR using only 14 variables, and 5 additional LSTM-based models using the same 517 variables as the first LSTM model and incorporating additional ML techniques (transfer learning, input perseveration, and ensembling). Performance was assessed using the area under the receiver operating characteristic (AUROC) curve at various times following HFNC initiation. The sensitivity, specificity, and positive and negative predictive values of predictions at 2 hours after HFNC initiation were also evaluated. These metrics were also computed for a cohort with primarily respiratory diagnoses. Results A total of 834 HFNC trials (455 [54.6%] training, 173 [20.7%] validation, and 206 [24.7%] test) met the inclusion criteria, of which 175 (21%; training: 103/455, 22.6%; validation: 30/173, 17.3%; test: 42/206, 20.4%) escalated to NIV or intubation. The LSTM models trained with transfer learning generally performed better than the LR models, with the best LSTM model achieving an AUROC of 0.78 versus 0.66 for the 14-variable LR and 0.71 for the 517-variable LR 2 hours after initiation. All models except for the 14-variable LR achieved higher AUROCs in the respiratory cohort than in the general intensive care unit population. Conclusions ML models trained using electronic medical record data were able to identify children at risk of HFNC failure within 24 hours of initiation. LSTM models that incorporated transfer learning, input data perseveration, and ensembling showed improved performance compared with the LR and standard LSTM models.
Collapse
Affiliation(s)
- George Pappy
- The Laura P. and Leland K. Whittier Virtual PICU, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Melissa Aczon
- The Laura P. and Leland K. Whittier Virtual PICU, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Randall Wetzel
- The Laura P. and Leland K. Whittier Virtual PICU, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - David Ledbetter
- The Laura P. and Leland K. Whittier Virtual PICU, Children's Hospital Los Angeles, Los Angeles, CA, United States
| |
Collapse
|
17
|
Iplik G, Yildizdas D, Yontem A. Clinical Factors of High-Flow Nasal Cannula Oxygen Success in Children. J Pediatr Intensive Care 2021; 12:71-78. [PMID: 36742258 PMCID: PMC9894699 DOI: 10.1055/s-0041-1730915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/08/2021] [Indexed: 02/07/2023] Open
Abstract
This study was aimed to evaluate the success rate of high-flow nasal cannula (HFNC) oxygen therapy and factors causing therapy failure. This prospective observational study included 131 children who received HFNC oxygen and followed-up in the pediatric emergency department, pediatric clinics, and pediatric intensive care unit between March 2018 and December 2019. The median age was 23.0 months (interquartile range [IQR]: 9.0-92.0) and 65 patients were male (49.6%). The most common reason for requiring HFNC oxygen therapy was pneumonia ( n = 75, 57.3%). A complex chronic condition was present in 112 (85.5%) patients. Therapy success was achieved in 116 patients (88.5%). The reason for requiring treatment and the patients' complex chronic condition did not affect the success of the therapy ( p = 0.294 and 0.091, respectively). In the first 24 hours of treatment, a significant improvement in pulse rate, respiratory rate, pH, and lactate level were observed in successful HFNC oxygen patients ( p < 0.05). In addition, these patients showed a significant improvement in SpO 2 and SpO 2 /FiO 2 ratio, and a significant decrease in FiO 2 and flow rate ( p < 0.05). HFNC oxygen success rate was 95.6% in patients with SpO 2 /FiO 2 ≥ 150 at the 24th hour; it was 58.0% in those with SpO 2 /FiO 2 < 150 ( p < 0.001). Caution should be exercised in terms of HFNC oxygen failure in patients with no significant improvement in vital signs and with SpO 2 /FiO 2 < 150 during treatment.
Collapse
Affiliation(s)
- Gokce Iplik
- Division of Pediatric Intensive Care Unit, Çukurova University Faculty of Medicine, Sarıçam, Adana, Turkey,Address for correspondence Gokce Iplik, MD Division of Pediatric Intensive Care Unit, Çukurova University Faculty of MedicineSarıçam, AdanaTurkey
| | - Dincer Yildizdas
- Division of Pediatric Intensive Care Unit, Çukurova University Faculty of Medicine, Sarıçam, Adana, Turkey
| | - Ahmet Yontem
- Division of Pediatric Intensive Care Unit, Çukurova University Faculty of Medicine, Sarıçam, Adana, Turkey
| |
Collapse
|
18
|
Impact of Failure of Noninvasive Ventilation on the Safety of Pediatric Tracheal Intubation. Crit Care Med 2021; 48:1503-1512. [PMID: 32701551 DOI: 10.1097/ccm.0000000000004500] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Noninvasive ventilation is widely used to avoid tracheal intubation in critically ill children. The objective of this study was to assess whether noninvasive ventilation failure was associated with severe tracheal intubation-associated events and severe oxygen desaturation during tracheal intubation. DESIGN Prospective multicenter cohort study of consecutive intubated patients using the National Emergency Airway Registry for Children registry. SETTING Thirteen PICUs (in 12 institutions) in the United States and Canada. PATIENTS All patients undergoing tracheal intubation in participating sites were included. Noninvasive ventilation failure group included children with any use of high-flow nasal cannula, continuous positive airway pressure, or bilevel noninvasive ventilation in the 6 hours prior to tracheal intubation. Primary tracheal intubation group included children without exposure to noninvasive ventilation within 6 hours before tracheal intubation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Severe tracheal intubation-associated events (cardiac arrest, esophageal intubation with delayed recognition, emesis with aspiration, hypotension requiring intervention, laryngospasm, pneumothorax, pneumomediastinum) and severe oxygen desaturation (< 70%) were recorded prospectively. The study included 956 tracheal intubation encounters; 424 tracheal intubations (44%) occurred after noninvasive ventilation failure, with a median of 13 hours (interquartile range, 4-38 hr) of noninvasive ventilation. Noninvasive ventilation failure group included more infants (47% vs 33%; p < 0.001) and patients with a respiratory diagnosis (56% vs 30%; p < 0.001). Noninvasive ventilation failure was not associated with severe tracheal intubation-associated events (5% vs 5% without noninvasive ventilation; p = 0.96) but was associated with severe desaturation (15% vs 9% without noninvasive ventilation; p = 0.005). After controlling for baseline differences, noninvasive ventilation failure was not independently associated with severe tracheal intubation-associated events (p = 0.35) or severe desaturation (p = 0.08). In the noninvasive ventilation failure group, higher FIO2 before tracheal intubation (≥ 70%) was associated with severe tracheal intubation-associated events. CONCLUSIONS Critically ill children are frequently exposed to noninvasive ventilation before intubation. Noninvasive ventilation failure was not independently associated with severe tracheal intubation-associated events or severe oxygen desaturation compared to primary tracheal intubation.
Collapse
|
19
|
Elliott SA, Gaudet LA, Fernandes RM, Vandermeer B, Freedman SB, Johnson DW, Plint AC, Klassen TP, Allain D, Hartling L. Comparative Efficacy of Bronchiolitis Interventions in Acute Care: A Network Meta-analysis. Pediatrics 2021; 147:peds.2020-040816. [PMID: 33893229 DOI: 10.1542/peds.2020-040816] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/06/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Uncertainty exists as to which treatments are most effective for bronchiolitis, with considerable practice variation within and across health care sites. OBJECTIVE A network meta-analysis to compare the effectiveness of common treatments for bronchiolitis in children aged ≤2 years. DATA SOURCES Medline, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform were searched from inception to September 1, 2019. STUDY SELECTION A total 150 randomized controlled trials comparing a placebo or active comparator with any bronchodilator, glucocorticoid steroid, hypertonic saline solution, antibiotic, helium-oxygen therapy, or high-flow oxygen therapy were included. DATA EXTRACTION Data were extracted by 1 reviewer and independently verified. Primary outcomes were admission rate on day 1 and by day 7 and hospital length of stay. Strength of evidence was assessed by using Confidence in Network Meta-Analysis . RESULTS Nebulized epinephrine (odds ratio: 0.64, 95% confidence interval [CI]: 0.44 to 0.93, low confidence) and nebulized hypertonic saline plus salbutamol (odds ratio: 0.44, 95% CI: 0.23 to 0.84, low confidence) reduced the admission rate on day 1. No treatment significantly reduced the admission rate on day 7. Nebulized hypertonic saline (mean difference: -0.64 days, 95% CI: -1.01 to -0.26, low confidence) and nebulized hypertonic saline plus epinephrine (mean difference: -0.91 days, 95% CI: -1.14 to -0.40, low confidence) reduced hospital length of stay. LIMITATIONS Because we did not report adverse events in this analysis, we cannot make inferences about the safety of these treatments. CONCLUSIONS Although hypertonic saline alone, or combined with epinephrine, may reduce an infant's stay in the hospital, poor strength of evidence necessitates additional rigorous trials.
Collapse
Affiliation(s)
- Sarah Alexandra Elliott
- Alberta Research Centre for Health Evidence and.,Cochrane Child Health, Department of Pediatrics, Faculty of Medicine and Dentistry, Edmonton Clinic Health Academy, University of Alberta Edmonton, Canada
| | | | - Ricardo M Fernandes
- Cochrane Child Health, Department of Pediatrics, Faculty of Medicine and Dentistry, Edmonton Clinic Health Academy, University of Alberta Edmonton, Canada.,Clinical Pharmacology and Therapeutics Laboratory, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, Lisboa, Portugal.,Department of Pediatrics, Hospital de Santa Maria, Avenida Professor Egas Moniz, Lisboa, Portugal
| | - Ben Vandermeer
- Cochrane Child Health, Department of Pediatrics, Faculty of Medicine and Dentistry, Edmonton Clinic Health Academy, University of Alberta Edmonton, Canada
| | - Stephen B Freedman
- Departments of Pediatrics, Emergency Medicine, and Physiology and Pharmacology, Cumming School of Medicine, Alberta Children's Hospital Research Institute, University of Calgary and Alberta Children's Hospital Foundation, Calgary, Canada
| | - David W Johnson
- Departments of Pediatrics, Emergency Medicine, and Physiology and Pharmacology, Cumming School of Medicine, Alberta Children's Hospital Research Institute, University of Calgary and Alberta Children's Hospital Foundation, Calgary, Canada
| | - Amy C Plint
- Division of Emergency Medicine, Department of Pediatrics, Faculty of Medicine, University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Terry P Klassen
- Children's Hospital Research Institute of Manitoba and Department of Pediatrics and Child Health, Max Rudy School of Medicine, University of Manitoba, Winnipeg, Canada; and
| | - Dominic Allain
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta and Stollery Children's Hospital, Edmonton, Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence and .,Cochrane Child Health, Department of Pediatrics, Faculty of Medicine and Dentistry, Edmonton Clinic Health Academy, University of Alberta Edmonton, Canada
| |
Collapse
|
20
|
Vo AT, Liu DR, Schmidt AR, Festekjian A. Capillary blood gas in infants with bronchiolitis: Can end-tidal capnography replace it? Am J Emerg Med 2021; 45:144-148. [PMID: 33915447 DOI: 10.1016/j.ajem.2021.04.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/15/2021] [Accepted: 04/19/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To explore the predictive ability of capillary blood gas (CBG) pCO2 for respiratory decompensation in infants aged ≤6 months with bronchiolitis admitted from the emergency department; to determine whether end-tidal CO2 (etCO2) capnography can serve as a less invasive substitute for CBG pCO2. STUDY DESIGN This was a prospective cohort study of previously healthy infants aged ≤6 months admitted for bronchiolitis from the emergency department (ED). Initial CBG pCO2 and etCO2 capnography were obtained in the ED prior to inpatient admission. Simple logistic regression modeling was used to examine the associations of CBG pCO2 and etCO2 capnography with respiratory decompensation. Pearson's correlation measured the relationship between CBG pCO2 and etCO2 capnography. RESULTS Of 134 patients, 61 had respiratory decompensation. There was a significant association between CBG pCO2 and respiratory decompensation (OR = 1.07, p = 0.003), even after outlying values were excluded (OR = 1.06, p = 0.005). End tidal CO2 capnography was not significantly associated with decompensation (OR = 1.02, p = 0.17), even after outlying values were excluded (OR = 1.02, p = 0.24). There was a moderate correlation between etCO2 capnography and CBG pCO2 (r = 0.39, p < 0.001). CONCLUSION In infants with bronchiolitis, CBG pCO2 provides an objective measure for predicting respiratory decompensation, and a single etCO2 measurement should not replace its use.
Collapse
Affiliation(s)
- Andrea T Vo
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd MS#113, LA, California 90027, USA.
| | - Deborah R Liu
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd MS#113, LA, California 90027, USA.
| | - Anita R Schmidt
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd MS#113, LA, California 90027, USA.
| | - Ara Festekjian
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd MS#113, LA, California 90027, USA.
| |
Collapse
|
21
|
Milési C, Requirand A, Douillard A, Baleine J, Nogué E, Matecki S, Amedro P, Pons-Odena M, Cambonie G. Assessment of Peak Inspiratory Flow in Young Infants with Acute Viral Bronchiolitis: Physiological Basis for Initial Flow Setting in Patients Supported with High-Flow Nasal Cannula. J Pediatr 2021; 231:239-245.e1. [PMID: 33333115 DOI: 10.1016/j.jpeds.2020.12.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 11/20/2020] [Accepted: 12/10/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess the inspiratory demand in young infants with acute viral bronchiolitis to provide a physiological basis for initial flow setting for patients supported with high flow nasal cannula. STUDY DESIGN Prospective study in 44 infants up to 6 months old with acute viral bronchiolitis, admitted to a pediatric intensive care unit from November 2017 to March 2019. Airflow measurements were performed using spirometry. The primary endpoint was the inspiratory demand as measured by peak tidal inspiratory flow (PTIF). The secondary endpoints were the relationships determined between PTIF, patient weight, and disease severity. RESULTS Median (Q25-Q75) age and weight of the patients were 37 (20-67) days and 4.3 (3.5-5.0) kg, respectively. Mean PTIF was 7.45 (95% CI 6.51-8.39, min-max: 2.40-16.00) L/minute. PTIF indexed to weight was 1.68 (95% CI 1.51-1.85, min-max: 0.67-3.00) L/kg/minute. PTIF was <2.5 L/kg/minute in 89% (95% CI 75-96) of infants. PTIF was correlated with weight (ρ= 0 .55, P < .001) but not with markers of disease severity, including modified Woods clinical asthma score, Silverman-Andersen score, respiratory rate, fraction of inspired oxygen, and PCO2. CONCLUSIONS High flow nasal cannula therapy is used commonly to support infants with acute viral bronchiolitis. The efficiency of the device is optimal if the flow setting matches the patient's inspiratory demand. According to our results, a flow rate of <2.5 L/kg/minute would be appropriate in most situations.
Collapse
Affiliation(s)
- Christophe Milési
- Pediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, Montpellier, France
| | - Anne Requirand
- Pediatric Functional Exploration Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| | - Aymeric Douillard
- Department of Medical Information, Montpellier University Hospital Center, Montpellier, France
| | - Julien Baleine
- Pediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, Montpellier, France
| | - Erika Nogué
- Department of Medical Information, Montpellier University Hospital Center, Montpellier, France
| | - Stephan Matecki
- Pediatric Functional Exploration Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France; PHYMEDEXP, CNRS UMR 9214, INSERM U1046, University of Montpellier, Montpellier, France
| | - Pascal Amedro
- PHYMEDEXP, CNRS UMR 9214, INSERM U1046, University of Montpellier, Montpellier, France; Pediatric Cardiology and Pulmonology Department, M3C Regional Reference Center, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| | - Marti Pons-Odena
- Pediatric Intensive Care Unit, Sant Joan de Deu University Hospital Center, University of Barcelona, Esplugues de Llobregat, Barcelona, Spain
| | - Gilles Cambonie
- Pediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, Montpellier, France; Pathogenesis and Control of Chronic Infection, INSERM UMR 1058, University of Montpellier, Montpellier, France.
| |
Collapse
|
22
|
Christophe M, Julien B, Gilles C. Improving synchrony in young infants supported by noninvasive ventilation for severe bronchiolitis: Yes, we can… so we should! Pediatr Pulmonol 2021; 56:319-322. [PMID: 33270991 DOI: 10.1002/ppul.25184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/01/2020] [Accepted: 11/15/2020] [Indexed: 11/07/2022]
Affiliation(s)
- Milési Christophe
- Department of Neonatal Medicine and Pediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| | - Baleine Julien
- Department of Neonatal Medicine and Pediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| | - Cambonie Gilles
- Department of Neonatal Medicine and Pediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| |
Collapse
|
23
|
Nagler J, Auerbach M, Monuteaux MC, Cheek JA, Babl FE, Oakley E, Nguyen L, Rao A, Dalton S, Lyttle MD, Mintegi S, Mistry RD, Dixon A, Rino P, Kohn-Loncarica G, Dalziel SR, Craig S. Exposure and confidence across critical airway procedures in pediatric emergency medicine: An international survey study. Am J Emerg Med 2020; 42:70-77. [PMID: 33453618 DOI: 10.1016/j.ajem.2020.12.075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/22/2020] [Accepted: 12/27/2020] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Airway management procedures are critical for emergency medicine (EM) physicians, but rarely performed skills in pediatric patients. Worldwide experience with respect to frequency and confidence in performing airway management skills has not been previously described. OBJECTIVES Our aims were 1) to determine the frequency with which emergency medicine physicians perform airway procedures including: bag-mask ventilation (BMV), endotracheal intubation (ETI), laryngeal mask airway (LMA) insertion, tracheostomy tube change (TTC), and surgical airways, and 2) to investigate predictors of procedural confidence regarding advanced airway management in children. METHODS A web-based survey of senior emergency physicians was distributed through the six research networks associated with Pediatric Emergency Research Network (PERN). Senior physician was defined as anyone working without direct supervision at any point in a 24-h cycle. Physicians were queried regarding their most recent clinical experience performing or supervising airway procedures, as well as with hands on practice time or procedural teaching. Reponses were dichotomized to within the last year, or ≥ 1 year. Confidence was assessed using a Likert scale for each procedure, with results for ETI and LMA stratified by age. Response levels were dichotomized to "not confident" or "confident." Multivariate regression models were used to assess relevant associations. RESULTS 1602 of 2446 (65%) eligible clinicians at 96 PERN sites responded. In the previous year, 1297 (85%) physicians reported having performed bag-mask ventilation, 900 (59%) had performed intubation, 248 (17%) had placed a laryngeal mask airway, 348 (23%) had changed a tracheostomy tube, and 18 (1%) had performed a surgical airway. Of respondents, 13% of physicians reported the opportunity to supervise but not provide ETI, 5% for LMA and 5% for BMV. The percentage of physicians reporting "confidence" in performing each procedure was: BMV (95%) TTC (43%), and surgical airway (16%). Clinician confidence in ETT and LMA varied by patient age. Supervision of an airway procedure was the strongest predictor of procedural confidence across airway procedures. CONCLUSION BMV and ETI were the most commonly performed pediatric airway procedures by emergency medicine physicians, and surgical airways are very infrequent. Supervising airway procedures may serve to maintain procedural confidence for physicians despite infrequent opportunities as the primary proceduralist.
Collapse
Affiliation(s)
- Joshua Nagler
- Boston Children's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Pediatric Emergency Care Applied Research Network (PECARN), USA.
| | - Marc Auerbach
- Yale University School of Medicine, New Haven, CT, USA; Pediatric Emergency Medicine Collaborative Research Committee (PEM-CRC), USA
| | - Michael C Monuteaux
- Boston Children's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - John A Cheek
- Emergency Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Emergency Department, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia; Paediatric Research in Emergency Departments International Collaborative (PREDICT), Australia and New Zealand
| | - Franz E Babl
- Emergency Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Emergency Department, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia; Paediatric Research in Emergency Departments International Collaborative (PREDICT), Australia and New Zealand; University of Melbourne, Melbourne, Australia
| | - Ed Oakley
- Emergency Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Emergency Department, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia; Paediatric Research in Emergency Departments International Collaborative (PREDICT), Australia and New Zealand; University of Melbourne, Melbourne, Australia
| | - Lucia Nguyen
- Peninsula Health, Frankston, Victoria, Australia
| | - Arjun Rao
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Australia and New Zealand; Sydney Children's Hospital (Randwick), NSW, Australia; University of New South Wales, Australia; Health Education Training Institute (HETI), New South Wales, Australia
| | - Sarah Dalton
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Australia and New Zealand; The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK; Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK; Paediatric Emergency Research in the United Kingdom & Ireland (PERUKI), UK
| | - Santiago Mintegi
- Pediatric Emergency Department, Cruces University Hospital, Bilbao, Spain; University of the Basque Country, Spain; Research in European Pediatric Emergency Medicine (REPEM), Spain; Red de Investigación de la Sociedad Española de Urgencias de Pediatría/Spanish Pediatric Emergency Research Group (RISeuP/SPERG), Spain
| | - Rakesh D Mistry
- Pediatric Emergency Medicine Collaborative Research Committee (PEM-CRC), USA; Children's Hospital Colorado, Aurora, CO, USA
| | - Andrew Dixon
- University of Alberta, Edmonton, Alberta, Canada; Stollery Children's Hospital, Edmonton, Alberta, Canada; Women's and Children's Health Research Institute, Canada; Pediatric Emergency Research Canada (PERC), Canada
| | - Pedro Rino
- Universidad de Buenos Aires, Argentina; Hospital de Pediatría "Prof. Dr. Juan P. Garrahan", Buenos Aires, Argentina; Red de Investigación y Desarrollo de la Emergencia Pediátrica Latinoamericana (RIDEPLA), Argentina
| | - Guillermo Kohn-Loncarica
- Universidad de Buenos Aires, Argentina; Hospital de Pediatría "Prof. Dr. Juan P. Garrahan", Buenos Aires, Argentina; Red de Investigación y Desarrollo de la Emergencia Pediátrica Latinoamericana (RIDEPLA), Argentina
| | - Stuart R Dalziel
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Australia and New Zealand; Starship Children's Hospital, Auckland, New Zealand; Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Simon Craig
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Australia and New Zealand; Paediatric Emergency Department, Monash Medical Centre, Melbourne, Australia; Department of Paediatrics, School of Clinical Sciences at Monash Health, Monash University, Australia
| | | |
Collapse
|
24
|
Suzanne M, Amaddeo A, Pin I, Milési C, Mortamet G. Weaning from noninvasive ventilation and high flow nasal cannula in bronchiolitis: A survey of practice. Pediatr Pulmonol 2020; 55:3104-3109. [PMID: 32511886 DOI: 10.1002/ppul.24890] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/03/2020] [Accepted: 06/04/2020] [Indexed: 01/09/2023]
Abstract
RATIONAL This study aims to describe the current weaning practices from any type of noninvasive support in infants with bronchiolitis, in terms of weaning procedures, weaning initiation and weaning failure criteria. WORKING HYPOTHESIS No information regarding the weaning practices is currently available and there may be a wide variability of strategies. STUDY DESIGN A cross-sectional electronic survey. METHODOLOGY The survey was distributed to physicians from five French-speaking countries with key roles in pediatric intensive care units (PICUs). RESULTS Responses were obtained from 29 PICUs from five French-speaking countries. A written weaning protocol was available in three pediatric centers (10%) and nurses had a key role in the weaning process in 72% of centers. The sudden weaning was the most commonly used procedure, no matter the type of noninvasive ventilatory (NIV) support. The most commonly used criteria for weaning initiation and weaning failure were the degree of respiratory distress, the occurrence of apneas and the fraction of inspired oxygen (FiO2 ). The thresholds commonly used for weaning initiation criteria were (a) none or a slight use of accessory muscles; (b) FiO2 less than equal to 40%, (c) respiratory rate less than 60 per minute, (d) no apnea, (e) blood pH more than 7.30, and (f) partial pressure of venous carbon dioxide less than equal to 50 mm Hg. CONCLUSION In infants with bronchiolitis requiring NIV support, the sudden weaning procedure was the most commonly used strategy. We observed a certain consensus on criteria for weaning initiation. These findings should help in building nurse-driven weaning protocols, but prospective studies remain needed to assess the best weaning strategy in infants with bronchiolitis-related acute respiratory failure.
Collapse
Affiliation(s)
- Marie Suzanne
- Pediatric Department, University Hospital of Grenoble-Alpes, La Tronche, France
| | - Alessandro Amaddeo
- Pediatric Noninvasive Ventilation and Sleep Unit, Necker Hospital, Paris, France
| | - Isabelle Pin
- Pediatric Department, University Hospital of Grenoble-Alpes, La Tronche, France
| | - Christophe Milési
- Pediatric Intensive Care Unit, University Hospital of Montpellier, Montpellier, France
| | - Guillaume Mortamet
- Pediatric Intensive Care Unit, University Hospital of Grenoble-Alpes, La Tronche, France
| |
Collapse
|